JUBILEE MISSION MEDICAL COLLEGE & RESEARCH INSTITUTE

NURSING PROCEDURE MANUA

Doc. No.: JMMCRI/NABH/DM/2

Issue No.: 2

Rev No.: 1

Date: 1-1-2026

Page: 20 of 265

AMENDMENT SHEET

SI. NO.	Date of Amendment	Section/Procedure Amended	Description of Amendment	Amended Page No	Revised Page No	Signature of the approval authority

CONTROL OF THE MANUAL

The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a readily identifiable and retrievable mode. The holder of the copy of this manual shall maintain it in current status by inserting latest amendments as and when the amended versions are received.

Quality Coordinator is responsible for issuing the amended copies to the copy holders, the copy holder should acknowledge the same and he/she should return the obsolete copies to the In-charge.

The amendment sheet, to be updated (as and when amendments received) and referred for details of amendments issued. The manual is reviewed once a year and is updated as relevant to the hospital policies & procedures. Review and amendment can happen, also as corrective actions to the non-conformities raised during the self-assessment or assessment audits by NABH. The authority over control of this manual is as follows:

Preparation	Verification	Approval	Issue
Assistant Nursing Superintendent Nurses Education	Assistant Director	Director	Quality Coordinator

The procedure manual with original signatures of the above on the title page is considered as ‘Master Copy’, and the photocopies of the master copy for the distribution are considered as ‘Controlled Copy’.

Distribution List of the Manual:

SL. No	Designation
1	Director
2	Quality Coordinator
3	Assistant Director- Nursing
4	Nursing Superintendent
5	Deputy Nursing Superintendent
6	Assistant Nursing Superintendent Nurses Education
7	Nursing In-charges
8	JMCON
9	JMSON

INDEX

Code	Section	Sub Section	Name	Page No
NM0101a	Admission & Discharge	Admission	Admission Procedure	7
NM0102a	Admission & Discharge	Discharge	Discharge Procedure	8
NM0201a	Initial Assessment		Initial Assessment	9
NM0301a	Bed making		Unoccupied bed making	16
NM0302a	Bed making		Occupied bed making	17
NM0401a	Vital Signs & Blood Pressure		Vital Signs & Blood Pressure	18
NM0501a	Care & Comfort		Sponge Bath	21
NM0502a	Care & Comfort		Bed Shampoo/Hair Wash	23
NM0503a	Care & Comfort		Mouth Care	24
NM0504a	Care & Comfort		Eye Care	25
NM0601a	Assessment	Collection of Specimen	GRBS Monitoring	26
NM0602a	Assessment	Collection of Specimen	Ketone Monitoring	26
NM0603a	Assessment	Collection of Specimen	Collection of specimen for C/S, R/E (Blood)	27
NM0603b	Assessment	Collection of Specimen	Collection of specimen for C/S, R/E 24 hrs (Urine)	29
NM0603c	Assessment	Collection of Specimen	Collection of specimen for C/S, R/E (Sputum)	31
NM0603d	Assessment	Collection of Specimen	Collection of specimen for C/S, R/E (Pus)	32
NM0604a	Assessment	Blood Gas Analysis	Blood Gas Testing – ABG & VBG	33
NM0604b	Assessment	Blood Gas Analysis	Blood Gas Analysis	35
NM0605a	Assessment		Activated Clothing Time Testing (ACT)	37
NM0606a	Assessment		Urine Albumin	38
NM0607a	Assessment		Assisting In Suprapubic Aspiration	38
NM0701a	Medication		Administration of Oral Medication	40
NM0702a	Medication	Injection	Administration of Intra Muscular Injection	41
NM0702b	Medication	Injection	Administration of Intravenous Injection	42
NM0702c	Medication	Injection	Administration of Subcutaneous Injection	43
NM0702d	Medication	Injection	Administration of Intra Dermal Injection	44
NM0702e	Medication	Injection	Assist in Intraosseous Injection	45
NM0703a	Medication	Instillation	Eye Instillation	48
NM0703b	Medication	Instillation	Ear Instillation	49
NM0703c	Medication	Instillation	Nose Instillation	50
NM0704a	Medication	Suppository &Enema	Vaginal Suppository	51
NM0704b	Medication	Suppository &Enema	Rectal Suppository	52
NM0704c	Medication	Suppository &Enema	Enema	53
NM0705a	Medication	Inhalation	Nebulisation	55
NM0706a	Medication		ASV Administration	56
NM0707a	Medication		Pulse Therapy	60
NM0708a	Medication		Biological Therapy (Rituximab,etc.)	61
NM0709a	Medication		Intravesical Therapy	62
NM0801a	Cannulation		Cannulation, Care & Removal	63
NM0901a	Infusions		IV Infusions	66
NM0902a	Infusions	Blood &Blood Components	Blood & Blood Component Transfusion	70
NM0902b	Infusions	Blood &Blood Components	Factor 8 Transfusion	71
NM1001a	Wound Care		Wound Dressing	73
NM1002a	Wound Care		Care of Pressure Injury	75
NM1101a	Symptomatic Management	Hot Application	Hot Water Bag Application	79
NM1101b	Symptomatic Management	Hot Application	Tepid Sponge	80
NM1101c	Symptomatic Management	Hot Application	Sitz Bath	81
NM1102a	Symptomatic Management		Steam Inhalation	81
NM1103a	Symptomatic Management		Management of Hypothermia/ Hyperthermia	83
NM1104a	Symptomatic Management		Stomach Wash	85
NM1105a	Symptomatic Management		Bladder Wash	86
NM1106a	Symptomatic Management		Stoma care	87
NM1107a	Symptomatic Management		Care of Unconscious Patient	88
NM1108a	Symptomatic Management		Pre & Post-Operative care	90
NM1109a	Symptomatic Management		Pre & Post care of Gastro Procedure	94
NM1201a	Oxygen Administration		Oxygen Administration	95
NM1301a	Airway Management		Assisting in Intubation & Extubation	97
NM1302a	Airway Management		Ventilator Management	100
NM1304a	Airway Management		Tracheostomy care & removal	104
NM1305a	Airway Management	Suctioning	Oral	106
NM1305b	Airway Management	Suctioning	Endotracheal Suctioning	107
NM1305c	Airway Management	Suctioning	Tracheostomy	109
NM1401a	Restraint		Restraint Procedure	110
NM1501a	Lines & Tubes		Assisting in insertion of Arterial Line, Care & Removal	112
NM1502a	Lines & Tubes		Assisting in insertion of Central Line, Care & Removal	115
NM1503a	Lines & Tubes		Assisting in insertion of external jugular vein cannulation	118
NM1504a	Lines & Tubes		Nasogastric insertion, Feeding & removal	121
NM1505a	Lines & Tubes		Urinary Catheterization, Care & Removal	124
NM1506a	Lines & Tubes		Assisting in Insertion of Intercostal Drainage, Care & Removal	127
NM1507a	Lines & Tubes		Assisting in Insertion of drain, Care & Removal	130
NM1601a	Equipment		Defibrillation	134
NM1602a	Equipment		ECG	134
NM1603a	Equipment		Syringe Pump	137
NM1604a	Equipment		Infusion Pump	139
NM1605a	Equipment		Multiparameter Monitoring	140
NM1606a	Equipment		Cardiac Output Monitoring	143
NM1607a	Equipment		C-Arm Operating	145
NM1610a	Equipment		HFNC	147
NM1701a	Resuscitation		BLS	151
NM1701b	Resuscitation		ALS	153
NM1703a	Resuscitation		NRP (Neonatal Resuscitation Program)	157
NM1801a	Patient Transportation		Patient Transfer & Mode of Transportation	160
NM1901a	Orthopaedics		Application of Traction	162
NM1902a	Orthopaedics		Application of Splint	167
NM1905a	Orthopaedics		Care of Patient with Traction(skin, pelvic, cervical)	169
NM2001a	Obstetrics & Gynaecology		Management of Labour	171
NM2003a	Obstetrics & Gynaecology		Care of Episiotomy	173
NM2004a	Obstetrics & Gynaecology		Management of High Risk Obstetric Cases	174
NM2005a	Obstetrics & Gynaecology		Cardiotocography	177
NM2006a	Obstetrics & Gynaecology		Fetal Doppler Scan	179
NM2101a	New Born		Care of New Born	180
NM2102a	New Born		Breast Feeding Techniques & Positions	182
NM2103a	New Born		Paladai Feeding	183
NM2104a	New Born		Kangaroo Mother Care	184
NM2105a	New Born		Early Intervention Program	186
NM2106a	New Born		Care of Baby in Phototherapy	188
NM2107a	New Born		Care of baby in Incubator	190
NM2108a	New Born		Care of Baby in Radiant Warmer	191
NM2109a	New Born		Assisting in Umblical Artery & Vein Catheterization, Care & Removal	192
NM2111a	New Born		Care of Patient with HFNC	194
NM2112a	New Born		Bubble CPAP	196
NM2113a	New Born		Assisting in Exchange Transfusion	200
NM2114a	New Born		Assisting in Surfactant Therapy	202
NM2115a	New Born		Peritoneal Dialysis	203
NM2116a	New Born		Immunization Schedule	205
NM2201a	Physiotherapy		Chest Physiotherapy	209
NM2202a	Physiotherapy		Postural Drainage	211
NM2301a	Death Care		Death Care	213
NM2404a	Cardiology		Assisting in ECMO	214
NM2406a	Cardiology		Care of Patient in IABP	217
NM2407a	Cardiology		Thrombolysis	219
NM2408a	Cardiology		Assisting in Pericardiocentesis	221
NM2409a	Cardiology		Care of Pig Tail	222
NM2501a	Chemotherapy		Managing/ Handling of chemo therapeutic drugs	224
NM2502a	Chemotherapy		Operation of Biosafety Cabinet	227
NM2503a	Chemotherapy		Assisting in Insertion, Care & Removal of Chemoport Needle	228
NM2601a	Burns		Care of Patient with Burns	229
NM2602a	Burns		Burns Wound Dressing	231
NM2701a	Nutrition		Jejunostomy Feeding	233
NM2702a	Nutrition		Percutaneous Endoscopic Gastrostomy Feeding	234
NM2801a	Additional Procedures		Assisting in Suturing, Care & Removal	236
NM2802a	Additional Procedures		Removal of Stapler	238
NM2803a	Additional Procedures		Assisting Pleural tapping/thoracentesis	239
NM2804a	Additional Procedures		Assisting Ascitic tapping/Abdominal paracentesis	241
NM2805a	Additional Procedures		Assisting Lumbar Puncture	242
NM2806a	Additional Procedures		Assisting in EVD procedure	244
NM2807a	Additional Procedures		Assisting Venesection (Draining)	247
NM2810a	Additional Procedures		Assisting Bone Marrow Aspiration	248
NM2811a	Additional Procedures		Assisting in Hydrostatic reduction procedure	249
NM2812a	Additional Procedures		Assisting in PR examination	251
NM2813a	Additional Procedures		Assisting in PV examination	252
NM2814a	Additional Procedures		Assisting in nerve blocks	253
NM2901a	Psychiatry		Assisting in ECT procedure	257
NM3001a	Dialysis		Hemodialysis	259
NM3002a	Dialysis		Plasmaphersis	262
NM3003a	Dialysis		Preparation of arteriovenous fistula & care	263
NM3005a	Dialysis		Reprocessing of Dialyzer & blood line	264
NM3102a	Cleft Lip & Palate		Feeding Infants with cleft lip & palate	265

NM0101a - ADMISSION PROCEDURE

DEFINITION

Emergent, urgent or routine admission of a patient in to an inpatient hospital facility for observation, investigation, treatment and care

PURPOSE

Ø To monitor and observe the client by doing investigation and to give appropriate treatment

Ø To acquire baseline data and prevent complications

Ø To offer immediate management and care in acute conditions

Ø To collaborate with the patient in planning and providing comprehensive care.

ARTICLES

· Vital signs tray

· Weighing machine

· All necessary articles required as per patient requirement. (Cannulation tray)

· Medical record with all necessary documents

PROCEDURE

NURSING ACTION	RATIONALE
Lower the bed and fold down top sheet and bed spread.	Make it convenient for the patient get into the bed.
Arrange room furniture for easy access from bed.	Reduces risk for fall.
Assemble special equipment such as suction equipment, oxygen supplies, pole for IV line, etc. and make sure they are in working condition.	Prevents delay in cases where immediate treatment is required.
Receive the patient and family cordially. Identify the patient with the admission slip. Allocate the bed no and complete the hospital information system of patient.
Introduce yourself and escort the patient and family to the assigned bed.	Reduces anxiety.
Prepare the medical record with all necessary information like name, hospital no, unit, room or ward, in each sheet.
Check for admission consent whether it is duly signed by patient and/or relative.
Instruct the patient that the ID band must wear throughout the hospital stay.
Perform the patient’s initial assessment with care plan within half an hour.	Provides base line data for assessment of condition on admission.
Orient patient to the physical set up of the ward such as nurse’s station, treatment room, toilet and bathroom facilities, drinking water supply, patient’s cupboard, etc. and also orient the patient to the ward routines.	Reduces the strain of finding the details by him.
Ensure about client’s insurance policy and provide necessary information.
Explain about the facilities available such as canteen, pharmacy, safety rules related to fire, accident, spiritual services, etc.
Explain the hospital policies regarding visiting hours, gate pass, attendants staying with patients and restrictions in the ward.
Initiate care which do not require physician’s order if needed, such as cold compress, tepid sponge
Encourage the patient to send the valuable to home. If the patient prefers to keep them, list the items and have the patient or family members sign it. Place the valuable in safe custody	Accounts for safe placements of valuables and prevent loss.
Inform the physician about patient’s admission and report any unusual findings	Patient’s condition may require immediate attention
Inform dietary department regarding patient’s arrival and type of diet ordered.	Patient’s condition may require immediate attention
Write the admission notes including the following details; date, time of patients arrival to the ward, age, mode of arrival, patient’s complaints for which he is hospitalized, variations in vital signs and any other abnormalities observed such as pressure sore ,rashes, etc., the orientation given and the full signature of the nurse. Record the admission in IP register, and Hospital information software.

NM0102a - DISCHARGE PROCEDURE

DEFINITION

Discharge is the formal release of an in-patient from an acute care institution after a period of hospitalization. It includes deaths in hospitals, discharge against medical advice, and referral out, but excludes transfers to other care units within the same institution.

GENERAL PRINCIPLES

Patient and family understands the diagnosis, anticipated level of functioning, discharge medications and anticipated medical follow-up.

Specialized instructions or training is provided to the patient and family to ensure that proper care after discharge will be provided to the patient.

Community support systems are coordinated to enable the patient to return home.

Relocation of the patient and coordination of support system or transfer to another health care facility are performed.

EQUIPMENT

· Wheelchair/stretcher

· All other articles as required

PROCEDURE

NURSING ACTION	RATIONALE
Assess the patient health care needs at the time of discharge using nursing history, care plan and ongoing assessment of physical abilities and cognitive function from time of admission.	Planning for discharge begins at the time of admission and continues throughout patient’s stay in the hospital.
Assess patients and family’s need for health teaching related to home therapies, restrictions resulting from health alterations and possible complications.	Improves understanding of health care needs and ability to achieve self-care at home.
Collaborate with physician and staff in other disciplines, e.g. Physical therapist, Social-worker, etc.	A multidisciplinary assessment ensures a comprehensive discharge plan.
Consult other health team members about needs after discharge, e.g. Dietician, Social worker. Make appropriate referrals.	Members of all health care disciplines should collaborate to determine patient’s needs and functional abilities.
Preparation before the day of discharge Conduct teaching sessions with patient and family as soon as possible during hospitalization in anticipation of preparation for discharge, e.g. signs and symptoms of complications. Use of medical equipment, etc.	Gives opportunities to practice new skills, ask questions and obtain necessary feedback.
Day of discharge a) Check the physician discharge order and inform the patient. b) Allow patient and family to ask questions c) Check physician’s discharge orders for prescription and change in treatment. d) Arrange the medical record to prepare the discharge summary. e) Replace the medicine and return remaining unused medicine for funding through pharmacy. f) Send the medical record for billing. g) Inform patient/ relative about the bill payment and collect the receipt after bill payment. h) Intimate the discharge to the hospital information system. i) Inform the patient relative to collect t discharge summary (2 copies) can be received from the same counter. j) Verify the discharge summary and keep a copy after obtaining signature of patient or relative. k) Ensure patient is instructed on medication, dietary restriction and follow-up care. l) Appropriate health instructions need to be given to the patient/relative, if discharged with communicable disease. m) Provide information about follow-up visit and home health care facilities available. n) Provide printed teaching material as per patient’s requirement with necessary instructions if required. o) Communicable disease need to be informed to the front office. p) For MLC cases, inform MLC office about the discharge for police intimation. q) Remove all invasive lines and clean the areas. r) Help the patient to change the hospital clothing to their own dress if any s) Return all valuable belongings if kept in safe custody. t) Complete documentation of patient’s discharge in nurse’s record. u) Discharge summary is given to all patients’ leaving the hospital including discharge against medical advice. v) Handover discharge summary after obtaining the bill clearance sheet. w) Remove ID band. x) Check washroom and drawers for belongings. y) Obtain wheelchair/stretcher for patients who are unable to ambulate and accompany to the vehicle. z) Arrange the hospital vehicle if needed.

NM0201a - INITIAL ASSESSMENT

INITIAL ASSESSMENT

The initial nursing assessment, the first step in the five steps of the nursing process, involves the systematic and continues collection of data, sorting, analyzing and organizing that data, and the documentation and communication of the data collected. Critical thinking skills applied during the nursing process provide a decision –making framework to develop and guide a plan of care for the patient incorporating evidence-based practice concepts.

Baseline information

The first part is to fill up the personal details and identification number of the patient, admission details and current diagnosis and treating doctor.it provides the baseline information about the patient.

Allergies

Includes two columns. One is drug with name specified and second is others .others include food or environmental. It helps to identify the intolerance to certain medications. It also reveals the nature of reaction and seriousness to these allergens.

Previous Surgery

This includes the year and name of the surgery.

Past History

This includes prior hospitalizations and major illnesses. Major illnesses includes diabetic mellitus (DM), hypertension (HTN), coronary artery diseases (CAD), thyroid disease, cerebrovascular accident (CVA) and others.

General appearance

General appearance assessment is a way to evaluate a patient’s overall health and appearance to provide clues about their health status. Patient general appearance can be identified as Normal, obese (if overweight) or emaciated (if thin and weak).

Respiratory system

Any deviation from normal breathing pattern like dyspnea, wheezing, cough or hemoptysis can be marked in this. Dyspnea is an uncomfortable feeling of not-being able to breathe well enough. Wheezing is high pitched whistling sound that occurs when breathing in or out. Hemoptysis is coughing up of blood or blood –stained mucus.

Cardiovascular system

Presence of swelling or edema, chest pain or palpitation can be mentioned in this. Press a finger on a swollen area of skin for 5-15 seconds. If a dimple or pit appears after the pressure is released, it indicates fluid build –up in the tissues. The depth and duration of the indentation can be measured. Palpitations are feeling of racing or pounding, fluttering of heart or skipping of a heartbeat that can be felt in chest, throat or neck. Auscultation helps to identify the palpitations.

Gastrointestinal system

This includes the assessment of nausea (feeling of vomiting), vomiting, hematemesis (vomits blood), diarrhea (frequent passage of loose, watery stool) or constipation (infrequent or difficult bowel movement).

Urinary system

If the patient has the symptoms like incontinence (voluntary leakage of urine), dysuria (pain and /or burning, stinging or itching of the urethra or urethral meatus associated with urination), retention (unable to empty all the urine from the bladder), hematuria (blood in urine).

Nervous system

a) Conscious – Patient open their eyes spontaneously, looks at you when spoken to in a normal voice, responds appropriately to stimuli, and movements are purposeful.

b) Unconscious – Reduced alertness, diminished wakefulness, and a decreased awareness of oneself and the environment.

c) Confused – feeling disoriented, struggling to pay attention, make decisions and remember things.

d) Coma – Patient is unarousable and their eyes remain closed. There are no purposeful responses to internal or external stimuli. However, non-purposeful responses to painful stimuli.

e) Tremors – Shaking or trembling movements in one or more part of the body and shaky voice.

f) Hemiplegia – Poor balance, difficulty walking, weakness of muscles or stiffness on one side of the body and difficulty grasping or holding on to objects.

g) Paraplegia – inability to voluntarily move the lower parts of the body.

h) Quadriplegia – Paralysis that affects all a person’s limbs and body from the neck down.

i) Speech – Relevant (appropriate and connected to the topic), irrelevant (impaired recall performance in the presence of irrelevant auditory stimuli),slurred (words become unclear or hard to comprehend), aphasia (unable to communicate like difficulty finding right words, halting or effortful speech and difficulty understanding what others are saying).

Emotional status

a) Calm – A state of being peaceful and free from worry.

b) Anxious – Feeling worried, uneasy or nervous which can be a normal reaction to stress.

c) Angry – Feeling or showing strong annoyance, displeasure or hostility.

d) Fearful – Describes a feeling of being scared or worried or an action that causes fear.

Musculo skeletal system

a) Fracture – Break or crack in the bone featured by intense pain, deformity, swelling, bruising, or trouble moving injured part.

b) Joint pain – Stiffness, soreness, or a burning, throbbing, or grating sensation on the joint.

c) Deformity – Deviation or distortion of the bone from its normal shape or size.

Skin

a) Intact – Healthy skin that is unbroken, without cuts, scrapes, or abnormal openings that could allow pathogens to enter the body.

b) Rash – Change in the skin’s appearance, color, or texture.

c) Blister – Small pocket of fluid that forms in the upper layers of the skin, usually in response to damage or injury.

d) Wound – Any disruption of or damage to living tissue such as skin, mucous membrane or organs.

e) Infection – Presence of redness, swelling, warmth, purulent discharge, papules or pustules.

f) Pressure injury – Pressure injury should be noted at the time of admission and the location, stage and size also to be noted.

Braden scale

Braden Scale (For Predicting Pressure Injury Risk) Severe Risk: ≤9 High Risk: 10-12 Moderate Risk : 13-14 Mild Risk: 15-18	Risk Factors	Score/ Description
	Sensory Perception	1.Completely Limited	2.Very Limited	3.Slightly Limited	4.No Impairment
	Moisture	1.Constantly Moist	2.Often Moist	3.Occasionally Moist	4.Rarely Moist
	Activity	1.Bedfast	2.Chair fast	3.Walks Occasionally	4.Walks Frequently
	Mobility	1.Completely Immobile	2.Very Limited	3.Slightly Limited	4.No Limitations
	Nutrition	1.Very Poor	2.Probably Inadequate	3.Adequate	4.Excellent
	Friction & Shear	1.Problem	2.Potential problem	3.No Apparent Problem
	Total Score :

Braden scale is a standardized, evidence –based assessment tool commonly used in health care to assess and document a patient risk for developing pressure injury.

Sensory Perception

It is defined as the ability to respond meaningfully to pressure –related discomfort. If a patient is unable to feel pressure –related discomfort and respond to it appropriately by moving or reporting pain, they are at high risk of developing a pressure injury. This risk category describes two different issues that affect sensory perception. These are patient level of consciousness and patient’s ability to feel cutaneous sensation.

Assessment category

Rating Description

Interventions

Sensory perception

4- No Impairment

Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort.

· Encourage the patient to report pain over bony prominences.

· Check heels daily.

Sensory perception

3- Slightly Limited

Responds to verbal commands, but cannot always communicate discomfort or the need to be turned.

Has a sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities.

· Assess and inspect skin second hourly. Pay attention to heels.

· Elevate heels and use protectors.

Sensory perception

2- Very Limited

Responds only to pain stimuli. Cannot communicate discomfort except by moaning or restlessness.

Has a sensory impairment that limits the ability to feel pain or discomfort over half of the body.

· Assess and inspect skin second hourly. Pay attention to heels.

· Elevate heels and use protectors.

· Consider special mattress or bed.

Sensory perception

1-Completely Limited

Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation.

Limited ability to feel pain over most of the body.

· Assess and inspect skin second hourly. Pay attention to heels.

· Elevate heels and use protectors.

· Consider special mattress or bed.

· Use pillows between knees and bony prominences to avoid direct contact.

Moisture

It is defined as the degree to which skin is exposed to moisture. Prolonged exposure to moisture increases the probability of skin breakdown. Moisture can come from several sources, such as perspiration, urine incontinence, stool incontinence, or wound drainage.

Assessment category	Rating Description	Interventions
Moisture	4- Rarely Moist. Skin in usually dry, linen only requires changing at routine intervals.	· Encourage the patient to use lotion to prevent skin cracks. · Encourage the patient to report any moisture problem.(such as under breast)
Moisture	3- Occasionally Moist. Skin is occasionally moist requiring an extra linen change approximately once per day.	· Encourage the patient to use lotion to prevent skin cracks. · Encourage the patient to report any moisture problem. (Such as under breast). · Use moisture barrier ointments (protective skin barrier). · Moisturize dry unbroken skin. · Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes. · Routinely check incontinence pads. · Avoid use of diapers but if necessary, check frequently (every 2-3 hours) and change as needed. · If stool incontinence, consider bowel training and toileting after meals.
Moisture	2- Often Moist. Skin is often but not always moist. Linen must be changed at least once per shift.	· Encourage the patient to use lotion to prevent skin cracks. · Encourage the patient to report any moisture problem. (Such as under breast). · Use moisture barrier ointments (protective skin barrier). · Moisturize dry unbroken skin. · Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes. · Routinely check incontinence pads. · Avoid use of diapers but if necessary, check frequently (every 2-3 hours) and change as needed. · If stool incontinence, consider bowel training and toileting after meals. · Consider a low air loss bed.
Moisture	1-Constantly moist	· Encourage the patient to use lotion to prevent skin cracks. · Encourage the patient to report any moisture problem. (Such as under breast). · Use moisture barrier ointments (protective skin barrier). · Moisturize dry unbroken skin. · Avoid hot water. Use mild soap and soft cloths or packaged cleanser wipes. · Routinely check incontinence pads. · Avoid use of diapers but if necessary, check frequently (every 2-3 hours) and change as needed. · If stool incontinence, consider bowel training and toileting after meals. · Consider a low air loss bed.
		· Assess and inspect skin second hourly. · Apply condom catheter if appropriate. · If stool incontinence, consider bowel training and toileting after meals or rectal tubes if appropriate.

Activity

It is defined as the degree of physical activity. Walking or moving from a bed to chair reduces patient risk of developing a pressure injury by redistributing pressure points and increasing blood oxygen flow to areas at risk.

Assessment category	Rating Description	Interventions
Activity	4- Walks Frequently Walks outside the room at least a day and inside the room at least once every two hours during walking hours.	· Encourage ambulation outside the room. · Check skin daily. · Monitor balance and endurance.
Activity	3- Walks occasionally Walks occasionally during the day, but for a very short distance with or without assistance. Spends the majority of each shift in bed or chair.	· Provide a structured mobility plan. · Consider a chair cushion. · Consider physical therapy consultation.
Activity	2- Chair Fast Ability to walk is severely limited or nonexistent. Cannot bear their own weight and/or must be assisted into chair or wheel chair.	· Consider a special chair pad. · Consider postural alignment, weight distribution, balance, stability, and pressure relief when positioning individuals in chairs or wheelchair. · Instruct the patient to reposition every 15 minutes when in the chair. · Stand every hour. · Pad bony prominences with foam wedges, rolled blankets or towels. · Consider physical therapy consult for conditioning and wheelchair assessment.
Activity	1-Bed fast	· Perform skin assessment and inspection second hourly. · Position prone if appropriate or elevate head of bed no more than 30 degrees. · Position with pillows to elevate the pressure points of the bed. · Consider special beds.] · Elevate heels off bed and /or use heel protectors. · Consider physical therapy consult for conditioning and wheel chair assessment. · Turn/reposition every one- two hours. · Post turning schedule. · Teach or do frequent small shifts of body weight.

Mobility

It is defined as the patient’s ability to change or control their body position.

Assessment category

Rating Description

Interventions

Mobility

4- No Limitations

Makes major and frequent changes in position without assistance.

· Check skin daily.

· Encourage ambulation outside the room at least twice daily.

· No interventions required.

Mobility

3- Slightly Limited

Makes frequent though slight changes in body or extremity position independently.

· Check skin daily.

· Turn/ reposition frequently.

· Teach frequent small shifts of body weight.

· Consult physical therapy for strengthening or conditioning.

· Use a gait belt for assistance.

Mobility

2- Very Limited

Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

· Perform skin assessment and inspection second hourly.

· Turn/reposition 1-2 hours.

· Post turning schedule.

· Teach or do frequent small shifts of body weight.

· Elevate heels.

· Consider a special bed.

Mobility

1- Completely immobile

Does not make even slight changes in body or extremity position without assistance.

· Perform skin assessment and inspection second hourly.

· Turn/reposition 1-2 hours.

· Post turning schedule.

· Teach or do frequent small shifts of body weight.

· Elevate heels.

· Consider a special bed.

Nutrition

Nutrition risk factor is defined by two categories, first the amount and type of oral intake, second amount received through tube feeding, total parenteral nutrition or are prescribed clear liquid diet or nothing by mouth.

Assessment category

Rating Description

Interventions

Nutrition

4.Excellent

Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

· Move the patient out of bed for all meals.

· Provide food choices.

· Offer nutrition supplements.

· Discuss a plan with the provider if the patient is NPO for greater than 24 hours.

· Record dietary intake.

Nutrition

3. Adequate

Eats over half of most meals. Eats a total of 4 servings of protein (meat and dairy products) each day. Occasionally refuses a meal ,but will take a supplement if offered

Is on a tube feeding or a TPN regimen that most likely meets most of nutritional needs.

· Observe and monitor nutritional intake.

· Discuss a plan with the provider if the patient is NPO for greater than 24 hours.

· Record dietary intake and I&O if appropriate.

Nutrition

2.Probably Inadequate

Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only 3 servings of meal or dairy products per day. Occasionally will take a dairy supplement.

Receives less than optimum amount of liquid diet or tube feeding.

· Observe and monitor nutritional intake.

· Discuss a plan with the provider if the patient is NPO for greater than 24 hours.

· Record dietary intake and I&O if appropriate.

· Encourage fluid intake as appropriate.

· Obtain nutritional /dietary consultation.

· Offer nutrition supplements and water.

· Encourage family to bring favorite foods.

· Provide small, frequent meals.

Nutrition

1.Very poor

Never eats a complete meal. Rarely eats more than one third of any food offered. Eats two servings of protein (meat or dairy products) per day. Takes fluid properly. Does not take a liquid dietary supplement.

Is NPO and/or maintained on clear liquids or IV for more than 5 days.

· Observe and monitor nutritional intake.

· Discuss a plan with the provider if the patient is NPO for greater than 24 hours.

· Record dietary intake and I&O if appropriate.

· Encourage fluid intake as appropriate.

· Obtain nutritional /dietary consult.

· Offer nutrition supplements and water.

· Encourage family to bring favorite foods.

· Provide small, frequent meals.

· Perform skin assessment and inspection second hourly.

Friction or Shear

Assessment category	Rating Description	Interventions
Friction/Shear	3-No Apparent problem Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.	· Keep bed linens clean, dry, and wrinkle free.
Friction/Shear	2-Potential Problem Moves feebly or requires minimal assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains a relatively good position in a chair or bed most of the time but occasionally slides down.	· Keep bed linens clean, dry, and wrinkle free. · Avoid massaging pressure points. · Apply transparent dressing or elbow /heel protectors to intact skin over elbows and heels.
Friction/Shear	1-Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.	· Keep bed linens clean, dry, and wrinkle free. · Avoid massaging pressure points. Apply transparent dressing or elbow /heel protectors to intact skin over elbows and heels. · Perform skin assessment and inspection second hourly. · Use a minimum of two people assisting plus a draw sheet in pulling the patient up in bed. · Keep bed linens clean, dry, wrinkle free. · Apply elbow /heel protectors to intact skin over elbows and heels. · Elevate head of bed 30 degrees or less to reduce shear when feasible.

Sleep

a) Adequate – Adults need at least 7 hours of quality sleep each night.

b) Disturbed – Unable hard to fall asleep or stay sleep.

Pain assessment

Assess whether patient is having pain. If yes follow daily pain assessment.

Vulnerability Assessment

Vulnerable group includes geriatric, pediatric, mentally challenged, differently abled, chemotherapy and others. If yes then nursing intervention related to vulnerability must be ensured.

Fall risk assessment (Morse fall Scale)

The Morse fall scale is a standardized fall risk assessment tool developed to identify patients who are more likely to experience a fall during hospitalization. The MFS functions as a point-based screening tool that assigns numerical weights to six clinical variables associated with falls. The MFS scoring system is interpreted as follows:-

Risk Level	Score	Action
Low Risk	0-24	Good basic nursing care
Moderate Risk	25-44	Follow standard fall prevention interventions
High Risk	≥45	Follow high risk fall prevention interventions

Variables	Numeric Values
History of failing	No	0
History of failing	Yes	25
Secondary Diagnosis	No	0
Secondary Diagnosis	Yes	25
Ambulatory Aid	None/Bed rest/ Nurse assist	0
	Crutches/ Cane/ Walker	15
	Furniture	30
IV/IV Access	No	0
	Yes	20
Gait	Normal/Bed rest/Wheelchair	0
	Weak	10
	Impaired	20
Mental Status	Oriented to own ability	0
	Overestimates or forgets limits	15
Total Score:

Fall prevention interventions:-

a) Remain with patient while toileting, do not turn lights off at night

b) Assist with bedside sitting, personal hygiene, and toileting

c) Observe /round every hour

d) Reorient confused patients as necessary.

e) Reinforce activity limits/ safety precautions with patient /family.

f) Instruct he patient to use assistive devices, as appropriate e.g. cane/walker

g) Evaluate and schedule type of medication

h) Ensure the patient wears personal glasses and/or hearing aids

i) Assess for numbness and decreased sensation in extremities

j) Vitamin D or calcium supplements

k) Manage and monitor hypotension

l) Address foot problems

m) Optimize vision

n) Assess and encourage fall risk reduction behaviors

o) Transition to maintenance exercise program when patient is ready

Malnutrition universal screening tool

It includes BMI score, weight loss score and acute disease effect score.

<18.5 =2, 18.5 – 20 =1, >20 =0 (BMI Score), <5=0, 5-10 =1,>10 =2 (unplanned weight loss), if patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days. (Score 2).If the score is more than 2 or more: dietician advice required.

Wells criteria for the prediction of DVT

Several clinical characteristics assessed in this criteria. These are

· Active cancer (treatment ongoing, within 6 months or palliative)

· Paralysis, Paresis or recent cast immobilization of the lower extremities.

· Recently bedridden for more than 3 days, or major surgery within 12 weeks requiring general or regional anesthesia.

· Localized tenderness along the distribution of the deep venous system.

· Entire leg swelling.

· Calf swelling at least 3cm larger than that on the asymptomatic side

· Pitting edema confined to the symptomatic leg

· Collateral superficial veins (non-varicose)

· Previously documented deep vein thrombosis

· Alternative diagnosis is at least as likely as deep vein thrombosis.

Each clinical characteristic score as one. Patients can be divided into “DVT unlikely “and DVT likely” groups based on wells score. An additional moderate risk group can be added based on the sensitivity of the d-dimer being used.

· The total score of 0 or lower is associated with “DVT unlikely” with a prevalence of DVT of 5%.

o These patients should proceed to d-dimer testing.

o A negative high or moderate sensitivity d-dimer results in a probability <1% and no further imaging is required.

o A positive d-dimer should proceed to ultrasonography testing.

§ A negative ultrasonography is sufficient for DVT rule out.

§ A positive ultrasonography is concerning for DVT; strongly consider treatment with anticoagulation.

· A score of 1-2 is considered moderate risk with a pretest probability of 17%.

o These patients should proceed to high-sensitivity d-dimer testing (moderate sensitivity d-dimer is not sufficient).

o A negative high sensitivity d-dimer is sufficient for rule out of DVT in a moderate risk patient with a probability of <1%.

o A positive high sensitivity d-dimer should proceed to ultrasonography testing.

§ A negative ultrasonography is sufficient to ruling out DVT.

§ A positive ultrasonography is concerning for DVT, strongly consider treatment with anticoagulation.

· A score of 3 or higher suggests DVT is likely. Pretest probability 17-53%

o All DVT likely patients should receive ultrasonography.

o D-dimer testing should be utilized to help risk- stratify these DVT-likely patients.

§ In DVT likely patients with negative d-dimer :

§ A negative ultrasonography is sufficient for ruling out DVT.

§ A positive ultrasonography should be concerning for DVT, strongly consider treatment with anticoagulation.

§ In DVT likely patient with positive d-dimer:

§ A positive ultrasonography should be concerning for DVT, strongly consider treatment with anticoagulation.

§ A negative ultrasonography is still concerning for DVT.A repeat ultrasonography should be performed within 1 week for re-evaluation.

Presence of tubing /others

It includes intravenous, catheters, drains, Ryle’s tube, dentures and others.

Orientation

Hospital orientation has to be given.

Assessment

Name, signature, date and time of the staff must be noted in the initial assessment.

NM0301a - UNOCCUPIED BED MAKING

MEANING

A bed prepared to receive a new patient is an unoccupied bed

PURPOSE

· To provide a clean and comfortable bed.

· To reduce the risk of infection by maintaining a clean environment.

· To provide a wrinkleless bed

ARTICLES

Bottom sheet

Mackintosh & draw cover

Blanket

Top sheet

Pillow cover

PREPARE THE AREA

Make sure the fan is off.

Adjust the height of the bed

Lower the side rails.

Move bedside furniture

Remove watch and jewelers.

Wash hands with soap solution.

Arrange the article in reverse order

ARRANGE THE ARTICLE IN REVERSE ORDER.

Pillow cover

Blanket

Top sheet

Draw sheet/ under pad

Mackintosh

Bottom sheet

PROCEDURE

NURSING ACTION	RATIONALE
Place stool at the foot end of the bed and place fresh linen in the reverse order	Keeping article at convenient place and within reach promote ease to work
Stand on the side of the bed	Unfolding the sheet in this manner allows you to make the bed on one side
Wash hands with soap and water.	Reduce the chance of transmission of micro-organism.
Take the bottom sheet and spread it
Tuck the sheet at head end, then foot end and along the sides by mitten corner	For smooth alignment. Mitten corner helps to provide a wrinkles free bed.
Place mackintosh and roll over to the opposite side.
Draw sheet placed on the middle side of the mackintosh and spread.
Move to the other side and tighten the bottom sheet and make mitten corners at the head and foot ends.
Tuck the mackintosh and draw sheet together on side.
Place the top sheet and spread the sheet and make a mitten corner.
Place blanket over the top sheet. Cuff the top of the sheet over the blanket.
Change the pillow case and replace pillow with free and facing away from the entrance of the room.	Pillow cover keeps cleanliness of the pillow and neat. The open end may collect dust/organisms.
Wash hands with soap and water.

NM0302a - OCCUPIED BED MAKING

MEANING

Making a comfortable bed with a patient who is confined to the bed.

PURPOSE

• To promote client comfort whose physical condition confines them to bed and for patients on imposed bed rest for therapeutic reason

• To change wet/soiled linen for the bed-ridden patient.

• To maintain neat appearance and clean environment.

• To provide a smooth wrinkle free bed foundation thus minimizing sources of skin irritation.

ARTICLE

• Clean gloves

• Bottom sheet

• Mackintosh & draw sheet

• Blanket

• Top sheet

• Pillow cover

• Laundry bag

• Dusters

PROCEDURE

NURSING ACTION	RATIONALE
Assess the patient general condition and check for any limitation in physical activity.	Determine the level of activity and ensures patient’s safety during the procedure.
Explain the procedure to the patient.	Providing information fosters cooperation.
Make sure the fan is off.
Move the furniture away from the bed.
Adjust the height of the bed.
Perform hand hygiene and wear gloves & mask (if needed).	To prevent the spread of infection.
Assembles all equipment and arrange on the bedside stool in the order of use.	Organization facilitates accurate skill performance.
Provide curtain for patient safety.	To maintain the client’s privacy.
Check the bed linen for patient’s personal items. Remove extra pillows.	To prevent personal belongings from damage a loss.
Loosen linen on all sides. Remove blanket leaving the top sheet over the patient.
Lower only the side rail of same side. Put up the side rail on opposite side. Turn the patient.	Moving the client as close to the other side of the bed as possible gives you more room to make the bed.
Place a pillow on the side to which the patient is turned.	Pillow is comfortable measure for the client.
Fan-fold the draw sheet and push it as close to the patient is turned.	Placing folded soiled linen close to the client allows more space to place the clean bottom sheets.
Clean and roll the mackintosh toward the patient.	Provides maximum work space for placing clean linen.
Fan-fold the bottom sheet towards the patient.	When the patient turns to the other side these soiled linen can be easily removed.
Dust the mattress with dry duster.	Dusting minimizes the number of microorganisms.
Place clean bottom linen in lengthwise and tuck at the head and foot end by making mitered corner.	Mitered corner will secure the sheet on the bed.
Bring mackintosh back into place and clean it using dry duster (if soiled replace the mackintosh). Place the clean draw sheet over the mackintosh and tuck both mackintosh and draw sheet under the mattress.	Protect the bed linen from soiling.
Put up the side rail.	Maintain safety.
Lower the side rails and assist the patient to roll slowly to the other side of bed over the fold of linen.	Exposes opposite side of bed for removal of soiled linen and placement of clean linen.
Remove the draw sheet by folding it into a bundle and place in the laundry bag. Remove the bottom sheet and place it in laundry bag. Clean and roll the mackintosh towards the patient.
Dust the mattress using a duster.	To prevent the spread of infection.
Pull the bottom sheet and tuck inside.	Wrinkled linen can cause skin irritation.
Tuck the mackintosh and draw sheet.	Tucking will keep the bed firm.
Assist the patient in rolling back to supine position and reposition the pillow.	Maintains patient comfort.
Place the top sheet and blanket over the patient and tuck it at the foot end.	Top sheet keeps the client warm and protect his or her privacy.
Adjust the pillows/comfort devices according to patient need.	Maintains patient comfort.
Raise the side rails.	Prevents fall.
Clean the bedside locker/table.	Provides neat appearance.
Remove gloves, mask and perform hand hygiene.	To prevent the spread of infection.
Record the observations made on the patient in the nurse’s notes.	Provide accurate documentation.

NM0401a - MONITORING VITAL SIGNS

INTRODUCTION

Vital signs are an objective measurement of the essential physiological functions of a living organism. They have the name “vital” as their measurement and assessment is the critical first step for any clinical evaluation. The first set of clinical examination is an evaluation of the vital signs of the patient. Triage of patients in an urgent /prompt care or an emergency department is based on their vital signs as it tells the physician the degree of derangement that is happening from the baseline.

TEMPERATURE

Body temperature is the difference between the amount of heat produced by body processes and the amount of heat lost to the external environment.

PURPOSE

To determine body temperature

• Assist in diagnosis.

• Evaluate patient’s recovery from illness.

• Determine if immediate measures should be implanted to reduce dangerously elevated body temperature or conserve body heat when body temperature is dangerously low.

• Evaluate patient’s response once heat-conserving or heat-reducing measures have been implemented.

PRINCIPLES OF THERMOREGULATION

The surface temperature of body varies with environmental changes.

The internal or core temperature is maintained within a very narrow range. Normally range is no more than a degree or so in a given individual.

Upper and lower limit of body temperature for survival are considered to be 46⁰C (114.8⁰F) and 20⁰C (68⁰F).

Heat is generated in the body through the process of cellular metabolism.

The generation and loss of heat is controlled thermostatically in the hypothalamus of the brain.

An elevated temperature is often one of the first signs of illness, except in children.

The maintenance of a temperature above the normal level requires expenditure of an increased amount of energy by the body.

A high body temperature may in itself stimulate further heat production.

Body tissue freezes when exposed to excessive by low environmental temperature.

Irreparable tissue damage can result in very high or very low body temperature if prompt intervention is not taken.

Infants and the elderly are more susceptible to changes in environmental temperatures than others.

Heat is lost from the body through the mechanisms of radiation, conduction, convection, and evaporation.

Body cells are damaged by excessive by high surface or internal temperature.

PULSE

Pulse is the palpable bounding of blood flow noted at various points on the body.

PURPOSES

• Determine the number of heart beats occurring per minute (rate).

• Gather information about heart rhythm and pattern of beats.

• Evaluate the volume (strength) of pulse.

• Assess the heart’s ability to deliver blood to distant areas of the body, viz. fingers and lower extremities.

• Assess response of the heart to cardiac medications, activity, and blood volume increase in IV infusions/blood transfusion.

• Assess vascular status of the limbs.

RESPIRATION

Noting the number of breaths per minute while simultaneously monitoring rate, rhythm, and depth of respirations per minute.

PURPOSES

• Determine the number of respirations occurring per minute.

• Gather information about rhythm and depth.

• Assess response of the patient to any related therapy/medication.

ARTICLES

• Medical record

• Clinical thermometer

• Alcohol swab

• Ball point pen

• Modified early warning score form

• Tissue /clean cloth piece

• Hand rub

• Watch with second hand

• Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient. Explain the procedure	Gain co-operation
Perform hand hygiene. Assemble the necessary articles	Prevents cross infection
Select the site with minimal exposure (axilla)	Ensure accurate placement of thermometer
Shake the thermometer and lower the mercury level to the lowest	Ensure accuracy in temperature reading
Wipe the thermometer using alcohol swab from bulb to stem in a rotatory manner	Wiping from least contaminated to most contaminated will prevent spread of micro-organism
Wipe the axilla with patient’s towel	Axilla may be moist from perspiration. This could affect the thermometer reading
Place thermometer in the axilla and lower the patients arm down across the chest	Provide a better contact of thermometer bulb in the axillary pit.
Leave the thermometer in place for 5minutes	Additional time is required for expansion of mercury to the maximum level
Position the patient supine, forearm straight alongside body or on a lower or upper abdomen with wrist extended.	Provides easy access to pulse site and relaxed position of lower arm permits full exposure of artery to palpation.
Use the first three fingers (excluding thumb) to palpate the patient’s radial artery (inner aspect of the wrist below the thumb).	The sensitive fingertips can feel the pulsation of the artery.
Apply gentle pressure so that the pulsation can be felt distinctly.	Pulse is more accurately assessed with moderate pressure. Too much pressure occludes pulse and impairs blood flow.
Palpate the radial pulse for complete one minute by placing tips of 3 fingers other than thumb	Irregularities can be identified only if pulse is counted for one complete minute. Thumb has its own pulse which can be mistaken as patients pulse Elasticity of the arterial walls, blood volume and mechanical action of the heart muscle are some of the actors that affect the strength of the pulse wave, which normally is full and strong.
Keep your fingers over the wrist as it checking pulse, while the patient’s hand is resting over his own lower chest or abdomen	Makes the patient less aware of his respiration. Keeping hand over lower chest/abdomen makes the chest movement visible
Position the patient comfortably with hand across chest, grasp patient’s wrist.	A similar position used during pulse assessment respiratory rate assessment as is to be inconspicuous.
Count the respiration for complete one minute. Assess the rate, depth, rhythm of respiration.	Irregularities in characteristics of respiration can be identified only if counted for one complete minute.
Remove the thermometer and wipe from stem to bulb using a dry cotton ball	Prevents cross infection
Read the thermometer by holding it at eye level. Shake down the mercury level and place it in the container	Reading at eye level prevents errors in reading
Perform hand hygiene with hand rub.	Prevents cross infection
Document the findings in the MEWS sheets. Report any abnormalities and give signature on the chart.	Prompt documentation avoids errors and provides continuation in care. Giving signature maintains professional accountability
Discard the waste and replace articles as per JMMC&RI policy. Perform hand hygiene using soap and water.	Prevents cross infection

NORMAL RANGE OF VITAL SIGNS

Vital parameters	Adult
Temperature	96.8⁰F-99.5⁰F
Pulse	60-100 beats/min
Respiration	12-20breaths/min

MONITORING BLOOD PRESSURE

DEFINITION

Blood pressure is the pressure exerted by circulating blood upon the walls of blood vessels.

PURPOSE

• To detect any changes from normal values

• To monitor the effectiveness of medication

• To control elevated blood pressure

ARTICLES

• Medical record

• Monitoring early warning score sheet

• Stethoscope

• Sphygmomanometer

• Blood pressure cuff of appropriate size

• Alcohol swab

• Hand rub

• Pen

PROCEDURE

NURSING ACTION	RATIONALE
Perform hand hygiene and assemble articles	Prevents cross infection and saves energy
Identify patient carefully	Ensures that right procedure is done on right patient
Explain the procedure to the patient	Gain co-operation and allay anxiety
Select the appropriate arm for application of the cuff	Measurement of blood pressure may temporarily impede circulation to the extremity
Have the patient assume a comfortable lying or sitting position with the forearm supported at the level of the heart and palm of the hand upward	The position of the arm can have a major influence when the blood pressure is measured
Expose the brachial artery by removing garments above the area where the cuff will be placed	Clothing over the artery interferes with the ability to hear sounds and may cause inaccurate blood pressure readings.
Palpate the location of the brachial artery. Tie the cuff about 2.5 to 5cm above the inner aspect of the elbow	Pressure applied directly to the artery provides the most accurate readings
Check that the needle on the mercury manometer is within the zero mark	If the needle is not in the zero area, the blood pressure measurement may not be accurate
Estimating systolic pressure Palpate the pulse at the brachial artery or radial artery by pressing gently with the finger tips	Palpation allows for measurement of the approximate systolic reading
Tighten the screw valve on the air pump	The bladder within the cuff will not inflate with the valve open
Inflate the cuff while continuing to palpate the artery. Note the point on the gauge where the pulse disappears.	The point where the pulse disappears provide an estimate of the systolic pressure
Deflate the cuff and wait for one minute	Allowing a brief pause continuing permits the blood to refill and circulate through the arm
Obtaining blood pressure measurement properly places the stethoscope earpieces in the ears.	Proper placements blocks extraneous noise and allow sounds to travel more clarify.
Place the bell or diaphragm of the stethoscope firmly but with as little pressure as possible over the brachial artery	Having the bell or diaphragm directly over the artery allows more accurate readings.
Pump the pressure 30mm Hg above the point at which the systolic pressure was palpated and estimated. Open the valve on the manometer and allow air to escape slowly	Increasing the pressure above the point where the pulse disappeared ensures a period before hearing the first sound that corresponds with the systolic pressure.
Note the point on the gauge at which the first faint, but clear, sound appears that slowly increases in intensity.(Koratkoff sounds)	Systolic pressure is the point at which the blood in the artery is first able
Do not re-inflate the cuff once the air is being released to recheck the systolic pressure reading	Re-inflating the cuff while obtaining the blood pressure is uncomfortable for the patient and may cause an inaccurate reading.
Note the point at which the sound completely disappears	The point at which the sound disappears corresponds to the beginning of diastolic pressure
Allow the remaining air to escape quickly	False readings are likely to occur, if there is congestion of blood in the limb while obtaining repeated readings.
When measurement is completed, remove the cuff
Document the findings in the vital signs chart/flow sheets. Report any abnormal readings.	Documentation provides continuity in care. Giving signature maintains professional accountability
Perform hand hygiene with hand rub.	Prevents cross infection
Discard the waste according to JMMCRI policy. Perform hand hygiene using soap and water.	To prevent cross infection

KORATKOFF SOUNDS

K1 (Phase 1) the appearance of the clear “tapping” sounds as the cuff is gradually deflated. The first clear tapping sound is defined as the systolic pressure.

K (Phase 2) The sounds in K2 becomes softer and longer and are 2 characterized by a swishing sound since the blood flow in the artery increases.

K3 (Phase 3) The sounds become crisper and louder in K3 which is similar to the sounds heard in K1.

K4 (Phase 4) As the blood flow starts to become less turbulent in the artery, the sounds in K4 are muffled and softer. Some professional record diastolic during Phase 4 and Phase 5.

K (Phase 5) In K5 the sounds disappear completely since the blood flow 5 through the artery has returned to normal. The last audible sound is defined as the diastolic pressure.

NM0501a - SPONGE BATH

DEFINITION

Cleansing the entire body of a dependent patient in bed

PURPOSE

To remove transient microorganisms, body secretions ,excretions and dead skin cells

To produce a feeling of well-being

To promote relaxation and comfort

To prevent or eliminate bad odor

To stimulate circulation

To improve self-esteem

ARTICLES

§ Medical record

§ Bedpan/urinal

§ Basin

§ Water(110-115⁰F)

§ Soap

§ Towels

§ Table or trolley

§ Clean gloves

§ Lotions

§ Bed linen

§ Patient clothing

PROCEDURE

NURSING ACTION	RATIONALE
Prepare patient and environment a)Explain procedure to patient and relative and encourage participation from patient or relative b) Close windows and doors and switch off fan/AC c) Provide privacy by drawing curtains and closing doors d)Raise side rails on both sides	Reduces anxiety and encourages cooperation Air currents increase loss of heat from the body Reduces patient embarrassment Enhances comfort of the patient
Prepare bed and position patient appropriately Place bed in a high position Position patient close to right side of the bed or close to nurse Raise side rails on both sides	Reduces strain to nurse’s back
Wash hands and put on clean gloves	Reduces transmission of micro-organisms
Lower side rails on the right side
Arrange articles within your reach
Make mitts with the wash cloth	Mitts conserve heat of water and prevents tip of wash cloth from trailing and dripping over patient’s body
Check temperature of water mixed in the basin by pouring water on the inner aspect of the palm of patient	prevents risk of burns
Remove patient’s clothing and cover with a bath blanket or sheet. Expose only that part of the body which is to be washed	Ensures privacy and prevent chills for the patient
Wash face a)Place one bath towel under patient’s head b) Wet bath mitt , squeeze water from it , so that it is not dribbling c)Wash patient’s eye using separate corners of the bath mitt for each eye and wipe from inner canthus to outer canthus d) Ask patient if he prefers e) If using soap , apply soap with the second mitt and then rinse the first mitt , till soap is removed fully f) wash, rinse, and dry patient’s face	Prevents wetting of pillows and bed linen Bath mitt retains temperature of water Prevents transmission of organisms from one eye to another, wiping from inner to outer canthus prevents secretions from entering nasolacrimal duct Soap has drying effect and face is more exposed to the air than any other body part and hence tends to the more drier Soap if remaining on skin will cause irritation
Wash arms and hand a) Place bath towel lengthwise under arm farther to you b) Wash apply soap, rinse and dry arms using long strokes from distal to proximal areas c) Pat dry using the 2nd batch towel. Do not rub d) Wash axilla well. Exercise precaution. If there is an IV infusion on arm e) Place folded towel on bed under hands, and place basin on it. Attend to interdigital spaces. Immerse hand in basin and assist patient in washing hand f) Repeat the entire procedure for other arm	Protects bed linen from becoming wet Firm strokes from distal to proximal areas will increase venous return Rubbing may cause skin injuries
Wash back of patient a) Turn patient to side lying or prone position and expose back b) Place towel to side lying or prone position and expose back c) Wash, rinse, and dry using long, firm strokes from neck to buttocks. d) Give back massage
Change bath water. Turn patient back to supine position
Wash legs, a) Place towel lengthwise under farther leg away from you b) Bend leg at knee, supporting under leg and ask patient to hold position. If patient is unable to do it, ask another nurse/family member to support leg c) Use long, firm strokes to wash from distal to proximal / from ankle to knee and knee to thigh. Do not use such long strokes in patients having blood clots in lower extremity d) Wash, rinse and dry the extremity e) Fold towel and place beneath foot of the patient. Place basin with water under the foot and clean with mitt f) Take out the foot and dry the extremity g)Discard water h) Repeat entire procedure for the other leg	Moving from distal to proximal improves venous circulation and removes dirt from skin pores
Encourage patient to clean perineal area with mitten. Discard it into a kidney tray	Promotes patient independence
Position patient in a comfortable manner
Apply moisturizer or body lotion if patient prefers or if skin is dry
Assist patient in dressing. Comb hair. Change bed linen. Wash hands. Record procedure. Replace all article

NM0502a - BED SHAMPOO / HAIR WASH

MEANING

Cleaning of hair with shampoo or soap to remove dirt, oil and odor on scalp and hair, for a helpless patient in bed.

PURPOSES

To keep hair clean and healthy

To prevent loss of hair

To prevent itching and irritation

To stimulate circulation

To enhance personal appearance and self-esteem

To provide a sense of wellbeing.

ARTICLES

Medical record

Bath towels-(2 Nos)

Washcloth or face towel

Mackintosh (big-1)

Non-absorbent cotton balls

Bath blanket/ sheet

Oil (optional)

Shampoo or liquid soap

Hair comb

Kidney tray or paper bag

Basin

Bucket-2

Mug

Clean linen

News paper

PROCEDURE

NURSING ACTION	RATIONALE
Assess the general condition of the patient, the scalp, hair and need for shampoo	Determines the presence of any condition that may require the use of special shampoo or treatment
Check the patient’s preference for soap shampoo
Explain procedure to the patient	Relieves the anxiety and helps the patient to co-operate
Assemble articles to bedside	Organization facilitates accurate skill performance
Close windows and switch off the fan	Prevents patient from hypothermia
Pull the curtains	Provide privacy for the patient
Wear gloves	Prevents cross contamination
Lower the head of the bed. Remove pillow and place protective pad under patient’s head and shoulders	Protect the sheets from getting wet
Make a trough will the mackintosh or use Kelly's pad if available	Allows dirty water to flow into the bucket
Unless contraindicated , move the patients head to the edge of the bed, position the diagonally with head positioned inside trough	Prevents over stretching and allows use of good body mechanics
Protect the pillow and bed with a mackintosh and towel	Prevents soiling of the bed
Place the bucket on a low stool close to the side of bed	Collect the dirty water
Plug the ears with cotton balls	Prevents shampoo entering into the ears
Place a wash cloth or a towel over the eyes	Prevents shampoo entering into the eyes.
Mix cold and hot water and test the temperature with the back of hand	Warm water is comfortable and facilitates removal of dirt and sebum
Pour warm water slowly over patient’s head, making sure that all hair is wet	It is more soothing for the patient
Apply shampoo and massage the scalp well	Rubbing and massaging of scalp adds to the comfort of the patient and effectiveness of shampoo
Rinse thoroughly with water	Remove soap and dirt
Dry hair with towel	To prevent him/her from becoming chilled.
Remove the trough and place it in the bucket. Discard the cotton plugs used to plug ears into the paper bag.
Reposition the patient in proper alignment	Improves patient comfort
Spread the hair over mackintosh and towel placed on the pillow and allow it to dry	Easy in drying
Change linen if wet	Provides a sense of neat appearance
Offer hot drink	To prevent him/her from becoming chilled
Take all articles to the utility room and clean them. Disinfect the towels, mackintosh, and basin ad bucket. Send soiled linen to laundry wash hands	To prepare for the next procedure
Return to bedside when the hair is dry. Comb and arrange the hair. Remove mackintosh and towel from the bed. Make the patient comfortable	To raise self-esteem. To prepare for the next procedure.
Record the procedure and report any abnormalities if present	Ensure communication between staff members

NM0503a - MOUTH CARE FOR UNCONSCIOUS PATIENT

MEANINNG

Performing cleansing of the teeth and mouth for an unconscious patient

PURPOSE

1. Maintaining integrity of the lips, tongue and mucous membrane of the mouth

2. Prevents oral infection

3. Prevent halitosis

4. Clean and moisten the membrane of the mouth and lips

ARTICLES

Tooth paste

Tooth brush

Sterile gauze

Sterile water

Lip moisturizer

Artery Curved forceps

Thumb forceps

Towel

Protective sheet

Clean gloves

Basin & mug

PROCEDURE

NURSING ACTION	RATIONALE
Assess patient (oral hygiene, gag reflex)	Comprehensive assessment is essential to determine individual needs
Explain the procedure to patient and relatives. Provide privacy.	Providing information fosters cooperation, understanding and participation in care
Wash and wear gloves	Promotes infection control
Place the patient in a side lying position, head turned to one side	Allows secretions to drain from mouth
Place the mackintosh under patient’s chest and towel under patient’s chin	Prevents soiling
Place kidney tray against patients chin	To receive the fluid from the mouth
Gently open the patients mouth by applying pressure to lower jaw/ insert padded tongue depressor	Provide access to oral cavity
Clean the teeth using Artery Curved forceps covered with gauze dipped in cleaning solution. Clean chewing surface first, then inner &outer surface from gum to crown	Ensures thorough cleaning and prevents injury
Clean the roof of mouth, gums and inner side of cheeks.	Ensures thorough cleaning and prevents injury
Clean the teeth tongue from back to front using Artery Curved forceps covered with gauze	Ensures thorough cleaning and prevents injury
Apply emollient to the lip using gauze	Lubrication prevents drying &cracking
Place the patient in comfortable position
Discard waste as per JMMCRI policy	To maintain standard precautions
Replace articles, remove gloves &wash hands	Prevents cross infection
Document procedure and patients response in nurse’s record	Documentation provides continuity and coordination of care and maintains professional accountability

NM0504a - EYE CARE

DEFINITION

Process of cleaning one/both eyes using prescribed solution for removing secretion and for preventing infection

PURPOSES

• To relieve pain and discomfort

• To prevent infection

• To prevent any further injury to the eye

• To provide instillation of an eye drop or application of an eye movement

ARTICLES

• Sterile tray

• Bowl small

• Forceps

• Dry gauze

• Normal saline

• K-basin

• Gloves

• Protective sheet

PROCEDURE

NURSING ACTION	RATIONALE
Check the physicians order	To obtain specific information
Explain to patient what will be done and how he may cooperate	Obtain patient consent and cooperation and promote patient education
Ensure privacy	Avoids unnecessary embracement
Prepare articles
Position the patient comfortably, preferably in the supine position or seated with head inclined backwards
Ensure adequate light source taking care not to dazzle the patient	Enables Maximum observation of the eye without causing the patient harm or discomfort
Check for any bruising, discharge or inflammation.	Assessment ease the treatment plan.
Perform hand hygiene.	Prevents infection
Always treat the uninfected eye first	Avoids cross-infection
Always bath the lid first, with the eyes closed.	Avoids secretion on the lid from entering into eyes
Lightly moisten swab in the prescribed solution	If the swab is too wet, the solution will run down patient’s cheek. This increases the risk of cross-infection
Gently swab from the inner canthus of the eye to the outer canthus using each swab only once until all discharge has been removed	Avoids the risk of discharge entering into the lachrymal duct
Gently dry the patient’s eyelids to remove excess moisture.
Repeat using a clean swab each time to reduce the risk of infection.
Ask the patient to look down and slightly evert the upper lid.
Clean the upper eye lid from medial canthus to outwards.
Ensure that the patient is comfortable
Discard the waste as per JJMCRI policy.
Remove gloves.
Perform hand hygiene
Document the procedure appropriately and report any abnormal findings

NM0601a - GRBS MONITORING

DEFINITION

GRBS monitoring is the measurement of concentration of glucose in the blood (glycaemia).

ARTICLE

Medical Record

Glucometer

Testing strip

Alcohol swab

Dry cotton

Disposable gloves

Sterile lancet

Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check the Doctor’s order.	Confirm time for checking random blood glucose.
Review manufactures instructions for glucometer use.	Helps in doing procedure accurately.
Explain the procedure to the client	Gain co-operation
Have the patient wash hands with soap and water.	Washing hands reduces transmission of microorganisms.
Gather the articles at the bedside.	Organization facilitates accurate skill performance
Position the patient comfortably in a semi-fowlers position or upright position.	Increases blood flow to puncture site.
Wash hands &don disposable gloves.	Prevents spread of microorganisms. Gloves protect from exposure to blood and body fluids.
Carefully tear the foil pouch from the tear gap and get the strip.	Avoid damaging or bending the test strip.
Turn monitor on and check whether the code number on strip matches with the code number on the monitor screen.	Matching the code numbers on the strip and glucometer ensures that machine is calibrated correctly.
Massage the side of finger for adults, heel for children toward puncture site and wipe with alcohol swab.	Massage increases blood flow to the area.
Use lateral side of the finger for adult and heel for children.	Reduces pain.
Never use center or tip of finger and avoid 1st, 2nd and 5^thfinger if possible.	Nerve ending, 1st and 2nd have callus.5th finger skin is thin.
Wipe the site with alcohol swab and allow it to air dry.	Promotes infection control.
Prick the site and wipe away the first drop of blood.	May contain large amount of serous fluid, can lead to false results
Lightly squeeze the site for the next drop and take it to the testing strip.	Facilitate accuracy in results.
Apply pressure to the puncture site using a dry cotton ball.	Stop bleeding
Read the result displayed on the monitor and inform the patient about result.
Remove the strip.
Dispose the used articles as per the JMMC&RI waste management policy.	Reduce contamination by blood. Sharps must always be handled properly to protect others from accidental injury.
Remove the gloves and discard. Wash hands.	Prevents cross infection.
Document the blood glucose level in the medical record	This facilitates documentation of procedure and provides for comprehensive care.

NM0602a - KETONE MONITORING

INTRODUCTION

Ketone monitoring enables the current plasma ketone concentration, allowing for diagnostic certainty and subsequent management plan.

Allows for timely change of treatment as necessary. It measures the beta-hydroxyl butyrate, the predominant ketone in Diabetic Ketoacidosis.

WHEN TO DO?

• All patient’s with suspected new type one diabetes.

• All patients with type 1 diabetes who are unwell and/or have vomited.

• All patient’s with urine ketones++ or+++.

• Any patient with diabetes (type1 or type2) and acidosis.

• In non-diabetic patients if ketosis is suspected.

ARTICLE

• Medical record

• Ketone monitor

• Testing strip

• Lancet pen

• Sterile Lancet

• Alcohol swab

• Dry cotton

• Gloves

• Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check for doctor’s order.	Confirm time for checking plasma ketone concentration.
Review manufacturer’s instruction for ketone meter use.	Helps in doing procedure accurately.
Explain the procedure to the patient.	Gain co-operation.
Have the patient wash hands with soap and water.	Washing hands reduces transmission of microorganisms.
Arrange the article at the bedside.	Organization facilitates accurate skill performance.
Position the patient in a semi fowler’s position or upright position.	Increase blood flow to puncture site.
Wash hands and don clean gloves.	Prevents spread of microorganism. Gloves protect from exposure to blood and body fluids.
Carefully tear the foil pouch from the tear gap and get the strip.	Avoid damaging or bending the strip.
Turn monitor on and check whether the code number on strip matches with the code number on the monitor screen.	Matching the code numbers on the strip and ketone meter ensures that machine is calibrated correctly.
Massage the side of finger for adults, heel for children toward puncture site.	Massage increases blood flow to the area.
Use lateral side of the finger for adult and heel for children.	Reduces pain.
Never use center or tip of finger and avoid 1st, 2nd and 5^th finger if possible.	Nerve ending, 1st and 2nd have callus.5th finger skin is thin.
Wipe the site with alcohol swab and allow it to air dry.	Promotes infection control.
Prick the site and wipe away the first drop of blood.	May contain large amount of serous fluid, can lead to false results.
Lightly squeeze the site for the next drop and take it to the testing strip.	Facilitate accuracy in results.
Apply pressure to the puncture site using a dry cotton ball.	Stop bleeding.
Read the result displayed on the monitor and inform the patient about result.
Remove the strip.
Dispose the used articles as per the JMMCRI waste management policy.	Reduce contamination by blood. Sharps must always be handled properly to protect others from accidental injury.
Remove the gloves and discard. Wash hands.	Prevents cross infection.
Document the ketone level in the medical record.	This facilitates documentation of procedure and provides for comprehensive care.

INTERPRETATION OF BLOOD KETONE

VALUE	INTERPRETATION
<0.6mmol/L	Normal
0.6-1.5mmol/L	Elevated level of ketone
1.6 to 2.9 mmol/L	At risk of DKA
>3mmol/L	Very high risk

NM0603a - COLLECTION of SPECIMEN (BLOOD)

Collecting venous blood specimen for routine testing

Meaning

Obtaining blood sample by vein puncture for routine lab investigation.

Purposes

For analysis of specific blood components individually or as a part of test panel

To determine abnormally in order to aid in diagnosis

Articles

• Medical record

• Tourniquet

• Gloves

• Specimen container with appropriate label

• Syringes 5ml/10ml

• No.20 gauge needles

• Antimicrobial swabs

• mackintosh

• Laboratory requisition form

• Sterile gauze

• Adhesive tapes

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician order & identify the patient	To reduce the errors
Reassure the patient & explain the procedure	To perform properly without any unnecessary venipuncture
Wash hands	Reduce transmission of micro-organism.
Provide proper position to patient & select the vein. Spread the trolley sheet	Select a vein that is visible, palpable & fixed to surrounding tissues.
Instruct the patient to extend his arm. Hold the arm straight at the elbow with fist clenched.	To make the position safe and comfortable is helpful to success venipuncture at one try
Apply the tourniquet 5-15 cm above the selected with just sufficient pressure to obstruct venous flow.	Tourniquet should remain in place no more than 60 seconds to prevent injury and lysis of specimen.
Clean the puncture site with anti-microbial swab in a circular motion & allow skin to dry flow.	Reduces risk of transmission of microorganism.
Use thumb of non-dominant hand to apply pressure and traction to the skin just below the puncture site before inserting needle.	Helps to immobilize and anchor the vein.
Insert the needle quickly and smoothly into vein at a 15⁰ angle to the skin. Hold the syringe between the thumb and last three fingers with the bevel up and directly in line with the course of the vein	Helps to immobilize and anchor the vein.
Obtain blood sample by gently pulling back on the plunger
Release the tourniquet and ask patient to open the wrist.	Reduces venous pressure and restores venous return
Place gauze over the puncture site and gently remove the needle from the vein.	Prevents injury to vein
Apply gentle but firm pressure to site for 2-4 min and provide comfortable position.	Applying pressure to the site prevents injury, bleeding.
Remove the needle from syringe and eject the blood the blood sample into vacutainer.
Invert the vacutainer gently 5-8 times.	To mix the blood with anticoagulant
Label the specimen correctly and send to lab with requisition form.	Proper labeling ensures accurate reporting of results.
Dispose needle and syringe in appropriate container.	Reduces the risk of transmission of micro-organism.
Remove gloves and wash hands.	Reduce the risk of transmission of micro-organism and contamination of other item.
Record the procedure; send the specimen to the laboratory immediately.	Timely transport ensures accurate results.

Collecting venous blood specimen for culture & sensitivity

DEFINITION

Obtaining blood sample for culture to detect septicemia, bacterial invasion through the blood stream.

PURPOSES

To determine antibiotic sensitivity of pathogen.

To culture pathogenic microorganism present in blood

ARTICLES

• Medical record

• Tourniquet

• Gloves

• Syringe 5ml/10ml

• Culture bottle with appropriate label

• Laboratory requisition form

• No.20 gauge needles

• Mackintosh

• Antimicrobial swabs requisition label

• Sterile gauze packs

• Adhesive tapes

PROCEDURE

NURSING ACTION	RATIONALE
Check the physicians order & identity the patient & explain the procedure.	Ensure performance of procedure on right patient
Gather necessary articles at bed side. Spread the trolley sheet	Obtain patients co-operation and confidence
Wash hands and put on gloves	Protects nurse from exposure to blood
Select and examine the vein, visualize the vein including the antecubital area, wrist, dorsum of the hand and top of foot. Palpate the vein
Instruct the patient to extend his arm. Hold the arm straight at the elbow with fist clenched	Proper positioning reduce risk of injury
Apply the tourniquet 5-15 cm above the selected site with just sufficient pressure to obstruct venous flow	Tourniquet helps to increase venous pressure and makes the vein more prominent and easier to enter
Cleanse the skin with 70% alcohol swab in a circular motion center to periphery. Allow to dry. Followed by betadine and 70% alcohol	Cleansing reduces the number of micro organisms
Clean the cover of the culture bottle with antiseptic swab.	Maintain sterility of equipment
Obtain 10ml-20ml of blood sample. Release the tourniquet and ask patient to open the fist	Restore circulation
Remove the needle and apply pressure in the puncture site dry with cotton	Pressure over the site prevents leakage of blood and hematoma formation
Change the needle with a fresh needle before injecting the blood into the bottles	Gentle ejection of blood prevents hemolysis
Push 10 ml blood into each of the bottles. While injecting blood into the bottles, be careful not to touch the sides of the bottle.	Maintain strict aseptic techniques.
Mix the blood and culture media by shaking the bottle gently
Discard the contaminated articles as per JMMCRI policy. Remove gloves and wash hands	Avoid possible spread of blood borne disease
Label the specimen correctly and send to lab with requisition form.	Avoid errors
Record the procedure into the patients chart with date and time of collection	Communication patient information to members of health care team

NM0603b - SPECIMEN COLLECTION

24 HOURS URINE COLLECTION

MEANING

Collection of urine for a period 24hrs in a special container without any spillage or wastage.

PURPOSE

•To detect kidney, liver, and cardiac conditions

•To measure total urine protein, creatinine, electrolyte, minerals, hormones

ARTICLES

· Clean labeled container with/without preservative , of not less than 3 liters capacity

· Urinal to collect urine at each voiding

· Laboratory requisition form

· Measuring cup

· Gloves

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician order and identify patient	Right procedure is done for right patient
Explain to the patient that all urine for the full 24 hours	Providing information fosters his/her cooperation
Instruct the patient to void at the time set to begin the procedure (e.g. at 6 am). Discard this specimen. Record in nurse’s note, the time when collection began.	Ensures that urine collection is within 24 hours testing
Measure and pour all the subsequent voiding into the container.	Accommodates all the variables in body chemistry within a period of time.
Collect the final specimen at exactly the same time the patient voided 24 hours	Ensure the client voids enough amount of the urine for the required tests
Send the container with urine to laboratory when the collection is over with requisition forms. Mention total volume of the specimen obtained.	Substances in urine decompose when exposed to air. Decomposition may alter the test results.
Discard the waste as per JMMCRI policy	Reduces the contamination.
Clean, disinfect and replace the urinal if they are reusable.	To prevent the spread of infection.
Perform hand hygiene.	Reduces the chances of spreading micro-organism.
Record in the nurse’s record time of completing the collection and dispatching the urine to the lab.	Provides continuity and professional accountability.

COLLECTING URINE SPECIMEN FOR URINALYSIS AND CULTURE

PURPOSE

To rule out urinary tract infection

To culture pathogenic micro-organism present in urine

To determine the characteristic of urine

To determine antibiotic sensitivity of the pathogen in the urine

ARTICLES

o Clean , wide-mouthed sterile container

o Bed pan or urinal

o Laboratory requisition form

o Gloves

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician order and identify the patient.	Right procedure is done to right patient.
Explain the procedure to the patient with specific instructions about washing the genital area with soap and water and give the labeled container.	Providing information fosters his/her cooperation and prevent errors.
Provide privacy.
Perform hand hygiene.	Reduces the chances of spreading micro-organisms.
Put on clean gloves and assist patient to collect urine	To prevent the spread of infection
Ask the patient to direct the first and last part of urine stream into a urinal or toilet and to collect the middle part of the stream into the specimen container	Collecting the midstream specimen ensures that fresh urine is analyzed.
Place lid on container and place specimen container in proper place	Helps to keep the specimen clean and prevent spills
Discard the waste as per JMMCRI policy.	Reduces contamination.
Remove gloves and perform hand hygiene.	Reduces the risk for infection transmission
Send specimen to the laboratory with completed. Signed laboratory form	Avoids errors
Record the procedure in the nurse’s record.	Provides continuity in care and professional accountability.

COLLECTING URINE SPECIMEN FOR URINALYSIS AND CULTURE FROM AN INDWELLING CATHETER

ARTICLES

Clean, wide-mouthed sterile container

Laboratory requisition form

10ml syringe with needle

Antiseptic swab

Labels for specimen container

Gloves

Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician order and Identify the patient by name and hospital no.	Right patient receives right procedure.
Explain the procedure to the patient.	Helps to prevent errors.
Perform hand hygiene	Reduces the transmission of micro-organisms.
Put on clean gloves and provide privacy.	Prevents spread of infection.
Clamp the catheter drainage tubing	Ensures collection of an adequate amount of fresh urine.
Cleanse the aspiration port or area between the ‘Y’ junction and the urine drainage port of Foley’s catheter with antimicrobial swab and allow port to air dry.	It prevents entry of micro-organism when the needle punctures the port
Insert needle in to aspiration port or the area between the ‘Y’ junction and the urine drainage port of Foley’s catheter and slowly aspirate enough urine for specimen	Ensures fresh urine specimen
Remove the needle from port and unclamp (if it’s clamped) the drainage tubing.	Collecting urine from the tubing guarantees fresh urine.
Slowly inject urine in to specimen container and replace lid on container.	Helps to keep the specimen clean and prevent spills
Discard the waste as per JMMCRI policy.	Prevents contamination
Remove gloves and perform hand hygiene.	Reduces the risk transmission of micro-organism.
Send labeled specimen to the laboratory with completed laboratory requisition form.	Timely transport ensures accuracy in results.
Document the procedure in the nurse’s record.	Ensures continuity in care and professional accountability

NM0603c - SPECIMEN COLLECTION (SPUTUM)

MEANING

Collection of specimen (sputum) is a procedure used to collect adequate respiratory secretions from patients to aid the diagnosis.

ARTICLES

· Sterile specimen container

· Sputum cup

· Tissue paper

· Gloves

· Kidney tray

· Suction catheter

· Suction apparatus

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician order and identify the patient by name and hospital no.	Right patient receives right procedure.
Explain the patient to collect sputum coughed up from back of the throat of lungs.
Ask the patient to sit erect in the bed if possible.	Helps the patient to cough and expectorate the sputum specimen.
Perform hand hygiene and put on gloves.	Prevent contamination.
Keep a sterile specimen container ready for the sample and take a tissue paper in hand.	Avoid any chance of outside contamination of the specimen or any contamination of other objects.
Remove lid of container and place with inner side facing upwards.	Prevent contamination.
Instruct the patient to take deep breaths and cough out deeply. Remove dentures if any.
Explain to the patient that he has to expectorate the sputum into sterile labeled container without touching the inside of it.	Proper explanation avoids errors
Close the container without touching inside lid.	Prevents contamination
Discard the waste as per JMMCRI policy	To reduce the chances of contamination.
Perform hand hygiene	Reduces the spread of micro-organism.
Provide client with tissue paper and a place in a comfortable position.	Makes the patient comfortable
Provide mouth care if patient needs it or encourage patient to carryout	Oral hygiene helps to remove pathogens from oral cavity
Document the relevant information in the nurses’ record.	Timely transport ensure accurate results

NM0603d - SPECIMEN COLLECTION (PUS)

DEFINITION

Collecting pus from the wound using a sterile swab stick or sterile container and placing it is a sterile tube by following aseptic technique.

PURPOSES

To identify the infecting organism this helps to take appropriate intervention.

EQUIPMENT

· Clean wide-mouthed sterile container/culture tube with 2 swab sticks

· Gloves

· Laboratory requisition form

· Cotton applicators

PROCEDURE

NURSING ACTION	RATIONALE
Review the doctor’s order for obtaining wound culture	Validates the correct patient and correct procedure.
Gather all necessary equipment and bring it to the bedside.	This promotes efficient time management and organized approach to the bedside conserves time and energy avoids unnecessary stretching and twisting of muscle on the part of the nurse.
Identify the patient.	Identifying the patient ensures right patient receives the right intervention and helps to prevent error.
Provide privacy.	Ensures patient privacy.
Explain procedure to the patient.	Relieves anxiety and facilitates cooperation.
Perform hand hygiene and put on personal protective equipment.	Prevents the spread of microorganisms based on transmission precaution.
Administer analgesic as per order.	Gives comfort to the patient by relieving pain and she gains more confidence in team member.
Place an appropriate waste receptacle within easy reach during the procedure.	Prevent spread of micro-organism.
Adjust the bed to most comfortable working height usually elbow height of the caregiver.	Prevents back and muscle strain.
Assist the patient to lie in a comfortable position.	Patient’s positioning provides comfort to the patient as well as for the nurse to perform any procedure.
Check the culture label against the patient’s hospital no.	Ensures that the correct patient and the correct specimen are sent to the laboratory.
Wear a clean glove and remove the adherent dressing, carefully without interrupting epithelialization.	Reduce the risk of contamination.
Note the presence, amount, type, color, and odor of any drainage on the dressing.	Helps to document presence and nature of drainage and condition of wound.
Remove gloves and wash hands.	Prevents the spread of micro-organisms.
Set up a sterile field, if indicated, and wound cleaning supplies put on the sterile gloves.	Maintain surgical asepsis.
Clean the wound with normal saline.	Removes previous drainage and wound debris, which could introduce extraneous organisms into the collected specimen, and give inaccurate results.
Dry the surrounding skin with gauze dressings	Provides a medium for growth of microorganisms, excess moisture can contribute to skin irritation.
Put on clean gloves.
Remove the nonabsorbent cotton from the culture tube ready. Place the swab stick sterile in the culture tube without getting contaminated by touching outside the tube.	Aseptic technique is maintained to prevent contamination of sterile swab from external wound and test tube.
Wear sterile gloves to separate the wound margins to permit insertion of swab deep into the wound with one hand manipulate the wound margins.	Prevents transmission of micro-organism.
Carefully insert the swab into the wound. Press and rotate several times over the wound surfaces.	Cotton swab absorbs wound drainage .contact with skin could introduce organism into the collected specimen.
Place the swab back into the culture tube. Does not touch the outside of the tube with the swab.	Protects from contamination with micro-organisms.
Remove gloves and discard them accordingly.	Reduces the risk for contamination
Wear another part of gloves and complete the dressing as per doctor’s order and secure the dressing.	Protects and promotes wound healing.
Remove the dressing and discard the waste as per JMMCRI policy.	Reduces the risk contamination.
Label the specimen and send it to the microbiology department immediately (not to leave in the refrigerator on leave days).	Ensures proper identification of specimen.
Remove the personal protective equipment and do the hand washing.	Reduces the risk for infection transmitted on and contamination of other items. Hand hygiene prevents the spread of microorganism.
Document all the relevant information in the nurse’s record.	Provides accurate communication on completion of procedure, patient’s response, and wound status.

NM0604a - BLOOD GAS TESTING

INTRODUCTION

Blood gas analysis is a test which measures the amounts of oxygen and carbon dioxide in the blood, as well as the acidity (pH) of the blood.

An ABG analysis evaluates how effectively the lungs are delivering oxygen to the blood and how efficiently they are eliminating carbon dioxide from it. The test also indicates that how well the lungs and kidneys are interacting to maintain normal blood pH (acid-base balance).

INDICATION

Acute respiratory distress syndrome

Severe sepsis

Septic shock

Hypovolemic shock

Diabetes –related ketoacidosis

Renal tubular acidosis

Acute respiratory failure

Acute heart failure

Cardiac arrest

Asthma attack

Inborn errors of metabolism

SITES

Radial artery

Brachial artery

Femoral artery

Dorsalis pedis artery

Ulnar artery

ARTICLES

· Medical record

· 2cc heparinised syringe

· Sterile gauze

· Kidney tray

· 20/26 gauge needle

· Alcohol swab

· Disposable gloves

· Lignocaine (optional)

· Barcode and label

· Adhesive tape

· Injection tray with Ice pack.

Normal range of blood gas analysis

HB-12to 14 gm/dl

PH-7.35 to 7.45

SO2-95 to 100%

Lac-0.5 to1.0 mmol/L

PO2-80-100 mm Hg

PCO2-35 to 45 mm Hg

Na+-135 to 145meq/L

K+-3.5 to 4.5meq/L

Ca++-4.4-5.2mg/Dl

HCO3- 22 to 26 mmol/L

SPO2-94-98%

Base Excess-+2 to -2 mmol/L

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician’s order	Ensure correct procedure.
Explain the procedure to the patient	To gain the co-operation.
Provide privacy.
Assemble article	Easy access for the procedure
Check the patient’s inspired oxygen concentration (FiO₂).	Degree of hypoxemia cannot be assessed without knowing the inspired oxygen concentration.
Check patient’s temperature.	Hypothermia or hyperthermia influences oxygen release from hemoglobin.
Perform hand hygiene.
Heparinize the 2 ml syringe. · Withdraw 0.1 ml heparin into the syringe to wet the plunger and fill dead space in the needle. · Hold syringe in an upright position and expel excess heparin and air bubbles.
Identify the site usually radial artery is preferred.
Perform arterial pressure on area where good pulses are palpable, e.g., brachial or femoral artery.
For radial artery puncture first perform Allen’s test. a. Obliterate the radial and ulnar pulses simultaneously by pressing on both blood vessels at the wrist. b. Ask patient to clench and unclench fist until blanching of skin occurs. c. Release pressure on ulnar artery (while still compressing radial artery) watch for return of skin color within 15 seconds. d. Obliterate the radial and ulnar pulses simultaneously at the wrist. e. Elevate patient’s hand above heart and squeeze or compress hand until blanching occurs. f. Lower patient’s hand while still compressing the ulnar artery and watch for return of skin color.	The Allen’s test is a simple method for assessing collateral circulation in the hand. If the ulnar artery does not have sufficient blood supply to perfuse entire hand, the radial artery should not be used. Identifies that ulnar artery alone is capable of supplying blood to the hand while radial artery is occluded. Identifies that radial artery alone is capable of supplying blood to the hand while ulnar artery is occluded.
Site of puncture is ½-1 inch proximal to wrist crease
For femoral artery puncture, extend arm at elbow and supine position with legs straight. Feel the pulse of femoral artery in the midline between the symphysis pubis and the anterior superior iliac crest, 2-4cm distal to the inguinal ligament. The puncture usually made distal to inguinal ligament.
Wash hands
Clean the area in circular motion with alcohol swab.	Reduce the chance of contamination.
Direct needle at approximately 45⁰-60⁰ angles towards pulsation.
Once the artery is punctured, arterial pressure will push plunger of syringe. Gentle aspiration is required to draw arterial blood.
Remove needle and apply pressure on puncture site for 5-10 minutes to avoid formation of hematoma
Expel air bubble from syringe.	Immediate analysis will give accurate result.
Transport the labeled sample in an injection tray with icepack. Send the sample to the nearest location of ABG analyzer. (If the ABG analyzer is not in the location.)
Analyze the sample immediately. Enter hospital number and other relevant data of the patient to the ABG analyzer. Wait for 1-2 minutes to obtain the result.
Discard the waste as per JMMCRI policy.
Perform hand hygiene and replace the articles.
Document the procedure and observation in nurse’s record.
Palpate the pulse, inspect the puncture site and assess for cold hand, numbness, tingling, or discoloration.

ABG THROUGH ARTERIAL LINE

Assess the catheter site for signs and symptoms of infection( erythema, drainage, swelling, pain, tenderness, induration )
Assess the distal portion of the access limb for adequate circulation.
Assess the catheter for the signs of mechanical damage or leaking.
Assess the integrity of the catheter exit site dressing. Replace a damp, loose, or visibly soiled dressing.
Disinfect the needleless connector on the sampling port of the arterial line. Use vigorous mechanical scrubbing for minimum of 5 to 60 seconds with alcohol swab and allow the solution to dry.
Suspend the arterial pressure alarm.	Suspending the alarm prevents sounding when the pressure waveform is lost during the blood draw.
Turn the stopcock of to the flush solution.
Obtain the discard blood specimen. Use a discard volume of at least two times the dead space of the catheter. Using sterile syringe, gently aspirate the discard volume.	Obtaining a discard volume clears the catheter of flush solution to prevent contamination of the blood specimen with fluid.
Discard the volume as per JMMCRI policy.
Slowly and gently aspirate the reservoir volume of blood in a sterile syringe.
Attach the sterile syringe and gently aspirate to obtain the required blood volume.
Aspirate the minimum volume to conserve blood.	The minimum volume of blood should be aspirated because a phlebotomy-related anemia is significant in all patient age group.
Hold the base of the sampling port and remove the syringe by pulling it straight out.
Open the stopcock by turning the handle parallel to the tubing.	Opening the stopcock allows reinfusion of the stored blood specimen.
Slowly and smoothly re-infuse the reservoir volume.	Re-infusing the reservoir volume helps reduce the risk of hospital acquired anemia.
Expel any air bubble from ABG syringe.	Expelling air bubbles from the ABG syringe.
Turn the stopcock off to the sampling port.
Flush any remaining blood from in the sampling port in the syringe.
Turn the stopcock off to the sampling port.	Turning the stopcock off to the sampling port opens the system for continuous arterial pressure monitoring.
Turn the alarms on and ensure that the waveform returns.
Further steps follow as per ABG analysis.

VENOUS BLOOD GAS ANALYSIS

The antecubital veins are the preferred vein for blood gas analysis.

Apply the vein 7-8 cm above the preferred site.

Insert the syringe at 30-45⁰⁺

Draw the blood slowly, within less than one minute of applying tourniquet.

Expel the air into a gauze piece.

Further steps follow as per ABG analysis.

Note

Central venous catheter and pulmonary artery catheter can be used to assess venous blood gas.

NM0604b BLOOD GAS ANALYSIS (CBG)

INTRODUCTION

Capillary blood gas analysis minimizes the iatrogenic blood loss in neonates. It is used particularly in neonates that are considered stable enough not to require invasive monitoring and also for STAT measurements prior to arterial catheterization.

DEFINITION

Capillary blood gas analysis is to estimate acid-base balance (pH) and adequacy of ventilation (PaCO2).

INDICATION

I. Arterial blood gas analysis is indicated but arterial access is not available.

II. Noninvasive monitor readings are abnormal: transcutaneous values,end-tidal CO2,pulse oximetry.

III. Assessment of initiation, administration, or change in therapeutic modalities (ie. Mechanical ventilation) is indicated.

IV. A change in patient status is detected by history or physical assessment.

V. Monitoring the severity and progression of a documented disease process is desirable.

CAPILLARY PUNCTURES SHOULD NOT BE PERFORMED

1. At or through the following sites

Posterior curvature of the heel, as the device may puncture the bone.

The heel of a patient who has begun walking and has callus development.

The fingers of neonates (to avoid nerve damage)

Previous puncture sites

Inflamed, swollen, or edematous tissues

Cyanotic or poorly perfuse tissues

Localized areas of infection.

Peripheral arteries.

2. When there is need for direct analysis of oxygenation.

3. When there is need for direct analysis of arterial blood.

ARTICLES

Medical record

Clean gloves

Alcohol swab

Lukewarm tap water

Capillary tubes (pre-heparinized), caps for tubes

Retractable incision device (Lancet)

Sterile gauze

Adhesive bandages

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient.
Arrange the articles and check the expiry of each item.
Assess the site for obtaining the blood, lateral or plantar surface of the heel.	The lateral limits of the calcaneous are marked by a line extending posteriorly from a point between the 4^th and 5^th toes and running parallel to the lateral aspect of the heel, as well as by a line extending posterioly from the middle of the big toe and running parallel to the medial aspect of the heel.
Puncture the skin on the plantar surface of the heel at a depth of no more than 2.0mm to prevent bone injury.	The distance between the skin and perichondrium is 2.4mm on the plantar surface and 1.2mm over the posterior surface. The vascular bed of skin lies 0.35- 1.6mm below the skin surface of the heel.
Do not use previous punctures site.	The accumulated tissue fluid will contaminate the blood sample.
Capillary tube must be filled with the correct volume of capillary blood.	It helps to ensure the correct final blood-additive ratio.
Perform arterialization when the site is cold or poor circulation by covering the puncture site with a warm, moist towel or other warming device at temperature of 42⁰C or less for 3-5 minutes prior to puncture.	It increases the arterial blood flow to the puncture site.
Wash hands.
Don gloves.
Cleanse the site using alcohol swab and allow drying.	It helps to allow the antiseptic effect and to prevent the discomfort due to residual alcohol.
Immobilize the patient with the assistance of a staff and perform skin puncture.
Wipe away the first drop of blood.	The first drop of blood contains interstitial and intracellular fluid that can contaminate the blood sample.
Obtain the second specimen to the capillary tube. Hold the puncture site downward and apply gentle continuous pressure to the surrounding tissue to improve flow of the blood.
Place the tip of the capillary device in the centre of the blood droplet and allow filling the capillary tube without air bubbles.
Seal both ends of capillary tube with caps.
Apply pressure to the site and bandage the heel.
Mix the sample thoroughly by rotating the tube back and fro for a minimum of 20 seconds.	This will mix the sample with heparin and reduce the clot formation.
Roll the capillary tube between the fingers for 10 times.
Remove the capillary tubes. Do not expel any blood onto a gauze pas to ensure sufficient sample volume for analysis.
Present the capillary tube to the analyzer and start analysis.
Sample with blood clot should not be used.	Clots can affect the accuracy of the test results and the fluidics of the instrument.
Blood gas analysis should be completed within 10 minutes and not longer than 30 minutes after withdrawing the blood.
Remove the capillary tube from the analyzer and dispose as per JMMCRI policy.
Replace the articles.
Doff gloves and wash hands.
Document all relevant information in the nurse’s record.

NM0605a - ACTIVATED CLOTTING TIME TESTING (ACT)

DEFINTION

The activated clotting time (ACT) is a test that is used primarily to monitor high dose of un-fractioned (standard) heparin therapy. ACT analysis give the most accurate at high doses of heparin. It is very cheaper, faster and can be done at the point of care

REFERENCE RANGE

70-120 seconds –time for blood to clot without heparin.

180-240 seconds- time for blood to clot with heparin (therapeutic range)

PURPOSE

Monitor anticoagulation effect.

To assess the level of anticoagulant.

For extra corporeal membrane oxygenation.

WHEN TO TAKE THE SAMPLE

Before removal of femoral catheter.

During cardiac surgeries.

ARTICLES

ACT machine

ACT vial

Syringe (2ml)

Sterile gauze

Gloves

Spirit swabs

PROCEDURE

NURSING ACTION	RATIONALE
Check doctors’ order and identify the patient.	Ensure that right procedure is done for right patient.
Assemble articles.	For easy access.
Wash hands.	Reduces the risk of infection.
Obtain fresh whole blood.
Fresh whole blood is added to a tube containing surface activator.
Tilt the tube up and down for 10 times to the surface activator.
Then tube is placed in an ACT machine for 60 seconds.
Tilted slowly every 5 seconds until a clot has formed. Time to clot formation is known as ACT.	Heparin prolongs the clotting time as it inhibits the thrombin formation.
Discard the article as per JMMCRI policy.	Reduces the contamination.
Replace the article.
Document the relevant data in nurse’s record.	Provides continuity in care.

NM0606a - URINE ALBUMIN (COLD TEST)

PURPOSE

Identify presence of albumin in urine

ARTICLE

¨ Medical record

¨ Test tube

¨ Test tube holder

¨ Syringe

¨ 3% sulphosalicylic acid solution

¨ Container with urine specimen

¨ Gloves

PROCEDURE

NURSING ACTION	RATIONALE
Check for physician’s order.	Ensure right patient.
Obtain the clean urine specimen from the patient.	Properly collected sample will give accurate result.
Wash hands and wear gloves.	To reduce the transfer of microorganism.
Hold the test tube with the holder	It helps to keep the test tube to hold without touching the test tube.
Pour equal amount of urine and 3% sulphosalicylic acid solution in a test-tube.	Acidification causes precipitation of protein in the sample (seen as increasing turbidity) which is subjectively graded as trace,1+,2+,3+ and 4+.
Observe for the formation of precipitate	Precipitate which indicates the presence of albumin.
Discard urine specimen and other single used items as JMMCRI policy, replace equipment and leave urine testing lab tidy	Proper disposal of soiled equipment prevents spread of infection
Document the results in nurse’s record

The results are interpreted as follows.
Negative/Trace	Clear or very mild cloudiness. Can read the letters in the background without any difficulty.
1(+)	Definite cloudiness present, but can read the letters in the background without any difficulty.
2(+)	Definite cloudiness present, cannot read the letters in the background.
3(+)	Definite cloudiness, precipitate present.
4(+)	Clots present.

NM0607a - ASSISTING IN SUPRAPUBIC ASPIRATION

DEFINITION

Suprapubic aspiration is a sterile procedure that allows for sampling of uncontaminated urine in patients. It is considered the gold standard for urine analysis in children aged 2-24 months.

INDICATION

1. Febrile child age 2-24 months with unknown source of fever.

2. Need for sterile urine collection when urinary catheterization is not possible such as,

· Labial adhesions

· Labial oedema

· Phimosis

· Children with a history of intraurethral /intraital surgery

3. Bladder outlet obstruction secondary to urethral stricture, urethral injury, malignancy, or prostrate hyperplasia.

CONTRAINDICATION

· Major abnormalities of the genitourinary tract.

· Non-palpable bladder or patient has urinated within one hour prior to the procedure.

· Patient’s with bladder cancer

· Overlying soft tissue infections of the abdominal wall.

· Abdominal wall skin trauma.

· Bleeding disorder such as thrombocytopenia or an elevated international normalized ratio (INR).

· Organomegaly or other intra-abdominal organ abnormalities.

· Abdominal distension.

· Uncooperative patient.

EQUIPMENT

· Medical record

· Antiseptic solution (povidone-iodine)

· Sterile gloves.

· Surgical hole towel.

· 1% lidocaine.

· 5ml syringe for anesthetic solution.

· 10 ml syringe for aspiration sample.

· In young children 22g or spinal needle for aspiration 1.5 to 3 inches long.

· In older children and adults: 22g or spinal needle for aspiration that is at least 3 inches long.

· 25g needle for drawing anesthetic solution.

· A sterile urine collection container.

· Sterile gauze.

· Sterile tight adhesive tape.

· If performing procedure with ultrasound guidance will also need

1. Portable ultrasound machine

2. Sterile ultrasound gel

3. Sterile ultrasound transducer cover.

PROCEDURE

NURSING ACTION	RATIONALE
Check physician’s order.	Prevent medication errors.
Identify the patient by name and hospital number.	Ensures that right procedure is done on right patient.
Assess the patient and explains the procedure.	Gain cooperation and allay anxiety.
Assemble all equipment near bedside.	For easy access.
Provide privacy.
Position the patient. For younger children: place the patient in supine with an assistant standing at the head of the bed, holding the patient in a frog-like position. For adults: supine position.	Helps the patient to cough and makes breathing easier.
Wash hands and don personal protective equipment.	Prevents cross contamination.
Assist the doctor for opening sterile package.
Hold the patient throughout the procedure to avoid the misplacement of the needle.
Assist the patient in cleaning the area.
Put on the sterile drapes.
Helps in loading the anesthesia drug.
Assist in insertion of sterile syringe to collect the urine. Restrict the patient movement throughout the procedure.
Transfer aspirated urine into a sterile collection bottle.
Clean the area, apply sterile gauze. Seal with a sterile tight adhesive tape.
Secure the bottle and transport immediately with properly filled requisition form.
Assess the patient status.
Dispose the waste as per JMMCRI policy.	Prevents contamination.
Remove personal protective equipment and perform hand hygiene.	Reduces spread of microbes.
Document (time, patient status during and after the procedure) all relevant information in nurses record.	Provides continuity in care and professional accountability.

COMPLICATION

· Transient gross or microscopic haematuria.

· Intestinal perforation.

· Bladder haematuria.

· Abdominal wall abscess.

NM0701a - ORAL MEDICATION

DEFINITION

Oral administration is a route of administration where a substance is taken through the mouth. Many medications are taken orally because they are intended to have a systemic effect, reaching different parts of the body via the bloodstream.

PURPOSE

To provide a medication that has systemic effect in the body or local effect on gastrointestinal effect.

CONTRA-INDICATION

• Alteration in normal functions of gastrointestinal tract like vomiting.

• Reduced gastrointestinal motility (after general anesthesia).

• Surgical resection of a portion of gastrointestinal tract.

• Inability to swallow.

• Patients with gastric suction/aspiration.

• Prior to certain tests/surgery.

• Unconscious/ confused patients.

• Patients with poor gag reflex.

EQUIPMENT

o Medical Record

o Medication tray

o Small plastic cups/paper cups/ bottle cups

o Glass of water

o Calibrated disposable cups/ounce glass for liquid medications

o Mortar and pestle

o Straight scissors

o Kidney tray

o Paper towel/tissue paper

PROCEDURE

NURSING ACTION	RATIONALE
Check physician’s order at drug kardex.	Prevent medication error
Identify the patient and assess the patient’s gag reflex.	Right procedure done for right patient.
Check medical record with physician’s written order for accuracy, completeness. Check patient’s name, name of drug, dose, route and time of administration.	Physician’s order is the legal and reliable source of information.
Follow ten rights of medicine administration.	Facilitate effective medicine administration.
Prepare drug a. Wash hand	Reduces transfer of microorganisms to medication and equipment.
b. Arrange medication tray	Saves time and reduces error.
c. Prepare medicine of one patient at a time, keeping medical record together.	Reduces the chances of error.
d. Calculate correct drug dose. Take time and double check calculation.	Provides accuracy and maintains cleanliness.
e. For tablets/capsules, pour required number from bottle into bottle cap and transfer to medication cup. Do not touch with fingers.	Retaining strips will help in identifying medication till the last tablet and thus reducing the error.
f. Place all tablets to be given at the same time in one cup.	Keeping such drug separately will help in withdrawing drug, if necessary.
g. If patient has difficulty in swallowing, grind tablets in a mortar with pestle.	Large tablets are difficult to swallow. When mixed with water, grinded tablets are easy to swallow.
h. Prepare liquids Shake bottle.
Hold bottle with label against palm of hand when pouring.	Label will not be soiled with spilled liquid.
Hold medication cup to eye level and fill it to desired level. Wipe the mouth of the bottle with paper towel.	Ensures accuracy. Prevents contamination of bottle contents and prevents cap from sticking.
i. Do not leave the drug unattended
j. Return drug container back to cupboard after checking label.	Third check of label reduces errors.
Administer drug a. Take medication to patient at correct time.	This gives information as to whether medications should be given at that time.
b. Identify patient by comparing name on medical record with the name patient gives when asked
c. Perform necessary pre-assessment.
d. Explain to patient about the medication to be given and allow patient to clarify doubts.	Patient has the right to be informed, and understanding of medications increases compliance to therapy.
e. Assist patient in sitting or side lying position.	Prevents aspiration.
f. Administer drug properly • Ask if patient wishes to hold medication in cup/hand before placing in mouth.
• Administer only one drug at a time.
• Offer a glass of water with the drug to be administered medication.
• Place medication under tongue and allow it to dissolve completely in case of sublingually administered medication.	Certain drugs when swallowed are destroyed by the gastric juices or rapidly detoxified by filter and thus therapeutic levels are not attained.
• Instruct patient to place the medication in mouth against cheeks until it dissolves completely in case of buccal administration.	Promotes local activity on mucus membrane.
• Prepare powdered medication at bed side and give to client.	When prepared in advance, powdered medication becomes more solid and difficult to swallow.
• Caution patient against chewing or swallowing lozenges.	Such drugs act by slow absorption through oral mucosa and not gastric mucosa.
• Give effervescent tablets immediately after dissolving.	Effervescence helps to improve taste of drug and is good for gastrointestinal tract problems.
g. Stay with the patient until each tablet is swallowed.	Nurse assumes responsibility for ensuring the patient receives ordered medication.
h. Assist the patient to comfortable position.	Maintains comfort.
i. Dispose of soiled supplies and wash hands.	Reduces transmission of micro- microorganism.
j. Record the medicine administration with date, time and signature at drug kardex.	Prompt documentation prevents errors such as repeated doses. Signature establishes accountability for administration.
k. Return within 30 minutes to evaluate effectiveness of medication.	Useful in detecting therapeutic effects and side effects.

NM0702a - INTRA MUSCULAR INJECTION

DEFINITION

Intramuscular injection (IM) is installing medications into the depth of specifically selected muscles. The bulky muscles have good vascularity, and therefore the injected drug quickly reaches the systemic circulation and thereafter into the specific region of action, bypassing the first-pass metabolism.

PURPOSES

To provide a medication the client requires

To administer vaccine

SITES

Ø Deltoid muscle of the arm

Ø Vastus lateralis muscle of the thigh

Ø Ventrogluteal muscle of the hip

Ø Dorsogluteal muscle of the buttock

ARTICLES

Ø Medical record

Ø Prescribed medication

Ø Sterile syringe

Ø Needle(22-25 gauge for adult, 25-27 gauge for children)

Ø Alcohol swabs

Ø Dry cotton

Ø Gloves

Ø Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check physician order at the drug kardex.	Confirm the doctor’s order.
Identify the patient by name and hospital no.	Avoid identity errors.
Explain the procedure and provide privacy.	Facilitates acceptance and compliance with procedure errors.
Follow ten rights in medicine administration.	Facilitate effective medicine administration.
Assemble all articles near bedside.	Having equipment available saves time and facilitates accurate skill performance.
Wash hands.	Reduce the spread of micro-organism.
Prepare medication from ampoule/vial.
Wash hands.	Reduces spread of microorganisms.
Follow three checks for administering the medication Ø When the medication taken from the patient’s bedside. Ø Before withdrawing the medication. Ø Before administering the medication.	Avoids medication errors.
Prepare the medication and change the needle before injection.	Does not irritate subcutaneous tissues as it passes into the muscle.
Position the patient.	Appropriate positioning promotes relaxation of the target muscle.
Provide privacy.
Select and clean the site with alcohol swab. Using a circular motion start from centre to periphery and allow skin to dry.	If alcohol enters tissue can cause irritation.
Remove the needle cover and discard without contaminating the needle Use separate needle for loading and administration.	Using the same needle may cause irritation to the subcutaneous tissue.
Insert the needle into the skin quickly and smoothly at a 90⁰angle inject the medication using a Z-track technique.	Quick motion lessens the client’s discomfort prevents discomfort and seepage of medication into the subcutaneous tissue.
Hold the barrel of the syringe with non-dominant hand and aspirate back with dominant hand (If blood appears, withdraw the needle, discard the syringe and prepare a new injection).	Confirmation of exact site.
If blood does not appear inject the medicine slowly and steadily.	Promotes comfort and allows time for tissue to expand and begin absorption of the medication.
Z-track technique Pull skin to one side, downward or laterally about an inch using non dominant hand. Inject medication at 90⁰angle. Hold needle in place for 10 seconds. Inject the medication slowly and steadily if blood does not appear in the syringe on aspiration.	Allow the medication to disperse evenly. This leaves a zig-zag that seals the needle track wherever tissue planes slide across each other. Drug can’t escape from the muscle tissue.
Withdraw the needle slowly and steadily while supporting at the hub of syringe and needle. With non-dominant hand, support the skin surface using the cotton gauze for applying counter traction at the site.	Support the skin surface with the cotton gauze helps to reduce discomfort. Applying counter traction prevents pulling of tissues when needle is withdrawn.
Dispose the articles as per JMMCRI policy and perform hand hygiene.	Reduce contamination.
Document all relevant information (time, drug, name, dose, and route) in drug kardex.	Reduces the chances of medication error and gives professional accountability.

NM0702b - INTRAVENOUS BOLUS INJECTION

DEFINITION

An IV bolus injection involves introducing a concentrated dose of a drug directly into the systemic circulation. IV bolus may be given directly into a vein or into an existing IV line through an injection port or through a saline or heparin lock.

PURPOSE

Used in emergencies with critically unstable patient.

To achieve immediate and maximum effect of a medication.

ARTICLES

Prescribed medicine

Syringe of appropriate size

Injection tray

Dry gauze

Antiseptic swab

Normal saline

Gloves

Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Ensure the physician’s order and identify patient	Ensure that right procedure is being done for the right patient
Assemble all needed articles in bedside	Avoid unnecessary intervention
Explain the procedure to the patient and get verbal consent	To gain co-operation
Perform hand hygiene.	To prevent contamination
Provide comfortable position to the patient and assess IV site	To provide comfort and to identify infiltration/ inflammation in the site
Perform hand hygiene and wear gloves.
Place sterile gauze under the Iv line. Prepare medication from vial/ampoule
Select and clean the port with antimicrobial swab	Cleaning deters entry of microorganisms
Occlude IV line by applying gentle pressure above the injection port	Causes minimum bleeding and patency of the vein is maintained
Pull back slightly on plunger until blood appears	It ensures injection of medication into blood stream
Inject pre-flush with normal saline.	To check patency of the IV line.
Inject medication slowly	Delivers correct amount of medication at proper interval
Observe IV site during injection for swelling	To determine infiltration in to surrounding tissues
Remove syringe by applying gentle pressure above	To determine infiltration in to surrounding tissues
Inject normal saline. Remove syringe and recap the cannula	To check the patency and position
Wipe the blood stains and remove the gauze under the cannula	Gives neat appearance.
Observe the patient and encourage the patient to verbalize any discomfort	To reduce any untoward effect
Discard sharps and waste properly JMMCRI protocol	To reduce the risk of cross infection
Replace article, remove gloves and perform hand hygiene	Prevents spread of infection
Document all relevant information in the medical record.	To maintain accurate records

NM0702c - SUBCUTANEOUS INJECTION

DEFINITION

A subcutaneous injection is given into the fatty tissue just beneath the skin. These injections are shallower than those injected into the muscle tissues.

There are fewer blood vessels in the fatty layer of connective tissue just beneath the skin than the muscle tissue so that medication injected subcutaneously is absorbed more slowly.

Many drugs that must be taken daily, or injected at home, are designed for subcutaneous injection.

PURPOSES

Ø To provide medication to the client requires (heparin, insulin).

Ø To administer Vaccine-(IPV, MMR, varicella, meningococcal polysaccharide, pneumococcal polysaccharide).

ARTICLES

Ø Medical record

Ø Sterile syringe& needle (23-25G and 3/8-5/8 inch long)

Ø Prescribed medication

Ø Alcohol swabs-2

Ø Dry cotton swab

Ø Gloves

Ø Kidney tray

Injection sites

· Fatty tissue over triceps

· Fatty tissue over anterolateral thigh

· Upper hip below the waist

· Abdomen, avoid 2 inch around the navel

Don’t select these sites

Ø The skin is burned, hardened, inflamed, swollen, or damaged by a previous injection.

PROCEDURE

NURSING ACTION	RATIONALE
Assemble equipment and check physician order at drug kardex.	Avoids medication errors. Facilitates skin in performing the procedure.
Identify patient carefully.	Ensures right procedure is done on right patient.
Explain procedure to patient.	Gain cooperation and allay anxiety.
Wash hands &wear gloves.	Reduce spread of microorganism.
Follow three checks for administering the medication Ø When the medication taken from the patient’s bedside. Ø Before withdrawing the medication. Ø Before administering the medication.	Avoids medication error.
Help patient to assume position depending on site selected and assess the area.	Ensures free access to injection site.
Provide privacy.
Clean the injection site with alcohol swab and allow drying.	To clean the skin.
Remove needle cap with non-dominant hand.	Lessons risk of an accidental needle prick.
Grasp and pinch the area surrounding the injection site.	Provides easy and less painful entry in to subcutaneous tissue.
Hold the syringe in dominant hand between thumb and forefinger. Inject needle quickly at an angle of 45-90⁰.	Needle position facilitates insertion into intradermal tissue. Dermis is relatively without vessels.
After insertion, release the tissue and aspirate (do not aspirate inj.Heparin).	To confirm the site. Aspirating inj.Heparin causes hematoma formation.
Inject medicine slowly.	Rapid injection of the medication creates pressure in the tissues and result in discomfort.
Withdraw needle quickly at the same angle as it was inserted, while applying counter traction around the injection site with non-dominant hand.
Do not recap the needle and discard the waste as per JMMCRI policy.	Prevents cross contamination.
Assist the patient to comfortable position.	Gives sense of well-being.
Replace articles, remove gloves and wash hands.	Reduce the transmission of microorganism.
Document all relevant information in drug kardex with nurse’ signature. (Date, time, dosage, name of medication, route) and any additional information at nurses record.	Timely documentation prevents administration errors.

NM0702d – INTRA DERMAL INJECTIONS

MEANING

Intradermal injections (ID) are shallow or superficial injection of a substance administered into the dermis, just below the epidermis. The ID injection route has the longest absorption time of all parenteral routes.

PURPOSE

Ø To perform sensitivity test.

Ø To perform diagnostic test (Mantoux).

Ø To administer vaccination.(BCG)

Ø For local effect (anesthesia).

SITE

Ø Inner aspect of upper third of the forearm.

Ø Upper anterior chest.

Ø Posterior thorax beneath the scapula.

ARTICLES

A tray containing;

Ø Medication

Ø Sterile 1ml/2ml syringe and needle(25-27gauge) and 1/4 to 5/8 inch long

Ø Gloves

Ø Alcohol swab

Ø Gauze piece

Ø Ball point pen (black or blue)

Ø Kidney tray

PROCEDURE

NURSES ACTION	RATIONALE
Check physicians order at drug cardex for medication administration and identify the patient.	Elimination of medication error.
Explain procedure to patient, the purpose, the site of injection, and how he has to co-operate.	Explanation encourages cooperation and reduces apprehension.
Wash hands with soap and water.	Reduces spread of micro-organisms.
Prepare medication from ampoule/ vial.
Wash hands with hand rub and wear gloves.	Reduces spread of micro-organisms.
Follow three checks for administering the medication. • When the medication taken from the patient’s bedside. • Before withdrawing the medication. • Before administration of the medication.	Avoid medication error.
Provide privacy.
Assemble all equipment including loaded medication at bed side.	Ensures free access to injection.
Position the patient and locate site for injection.	Forearm is the most convenient and easily located and hence the commonly used site.
Cleanse the site with alcohol swab in circular motion outward and allow skin to dry.	Pathogen in the skin can be introduces into tissues. Alcohol if enters, tissues can cause irritation.
Remove the needle cap with non-dominant hand by pulling it straight off.	Reduces the chance of contamination of needle.
Use non-dominant hand to spread the skin over injection site.	Provides an easy entrance into skin.
Hold the syringe parallel to skin and insert needle at 5-15⁰ angle with bevel facing up. Do not aspirate.	Needle position facilitates insertion in to intra-dermal tissue. Dermis is relatively without vessels.
Slowly inject the drug (0.01-0.1 ml). Waiting for a bleb or blister to develop.	Appearance of a bleb indicates that needle is in intra-dermal tissue.
Withdraw needle quickly in the same angle as it was inserted. Mop the area gently using dry gauze.	Reduces tissue damage and discomfort of patient.
Do not massage.	Massaging the area will lead to spread of medication to subcutaneous tissue and fails results may occur.
Do not recap the needle. Safety discards syringe and needle into appropriate receptacle.	Reduces the risk of accidental puncture with needle.
Encircle the bleb/blister with date, time, and name of the medication.	Allow easy identification of site.
Assist the patient to be in comfortable position.
Discard the article as per JMMCRI policy.	Prevents cross contamination.
Replace articles, remove gloves and wash hands.	To reduce the spread of micro-organisms.
Obtain patient response regarding any discomfort/itching at the site within 30 minutes.
Document all relevant information in drug kardex (dose, route, name of medicine, time, and patient’s response) and any additional information at nurse’s record.	Provide continuity in care and professional accountability.

NM0702e - ASSIST IN INTRAOSSEOUS INJECTION

INTRODUCTION

Intraosseous vascular access refers to the placement of specialized hollow bore needle through the cortex of a bone into the medullary space for infusion of medical therapy and laboratory test.

TERMINOLOGY

Intraosseous space: Intraosseous space refers to the spongy, cancellous bone of the epiphysis and the medullary cavity of the diaphysis, which are connected. The vessels of the IO space connect to the central circulation by a series of longitudinal canals that contain an artery and a vein. Volkmann’s canals connect the IO vasculature with the major arteries and veins of the central circulation.

SITES

Sternum

Humeral head

Iliac crest

Distal femur

Proximal tibia

Distal tibia

Sternum: 1cm below the sternal notch.

Humerus: The humerus should be internally rotated and the hand placed on the abdomen with the elbow flexed to 90⁰, ensuring that the biceps tendon is medially located and not penetrated. The surgical neck is palpated, and the needle is placed 2cm above the surgical neck into greater tubercle at about 45⁰ to the anterior plane.

Distal femur: with leg straightened and centered in the anterior plane, 1cm proximal to the patella, and 1 to 2cm medially.

Proximal tibia: 1cm to 2cm inferior and medial to the tibial tuberosity in the flat portion of the tibia.

Distal tibia: 2cm proximal to the medial malleolus in the flat portion of the tibia.

INDICATIONS

Unable to obtain venous access or delayed venous access

Immediate vascular access is required

Blood for laboratory analysis or point of care testing.

Access needed for contrast injection for radiologic evaluation.

CONTRA INDICATIONS

Adequate venous access

Fracture of the boney site

Burn site

Cellulitis or infection at the site

Osteogenesis imperfect

Osteoporosis

Previous IO attempted site

Previous IO site less than 48hours

Recent orthopedic surgery

ARTICLES

· Medical record

· Antiseptic solution

· Towels (rolled up)

· Sterile gloves

· The IO vascular access needle

· Bone injection gun

· Syringes 5 -60ml based on the anticipated need

· Sterile saline for flush

· Sterile gauze

· Local anesthesia

· IV connection tube and fluids

· Local anesthetic (1% lidocaine)

· 22-25 gauge needle

PROCEDURE

NURSING ACTION	RATIONALE
Check for the doctor’s order	Avoid errors.
Check the hospital no. of the patient.	Right procedure is done for the right patient.
Assist the physician to locate the site.	To identify the appropriate location.
Position the patient supine.
Place a towel roll behind the knee if the proximal tibia or distal femur is to be cannulated.
Arrange the article at the patient side	Ease access.
Pre-flush all IV lines and connecting tubes with normal saline.
Prepare a syringe with 5 to 10 ml normal saline.
For the insertion site-anesthesia, draw 5ml of 1% lidocaine into a syringe and attach 25 gauge needle.
For medullary space anesthesia, draw 5ml of 2% preservative free IV lidocaine into a syringe.
Swab the area of skin around the cannulation site with antiseptic solution using outwardly expanding concentric circles.	Ensure sterile area for insertion.
Palpate the insertion site.
Stabilize the insertion site, wrapping around the extremity near the site.
Prepare the local anesthetic agent and the assist the physician to give the injection.	It enhances the co-operation of the patient by reducing the pain.
Physician firmly holds the drill or the manual needle. Position the needle tip at the point insertion, perpendicular to the long axis of the bone.
Stabilize the needle shaft at the skin surface with an index finger. Advance the needle with moderate pressure and to-and fro rotary, coring (screwing) motion. Immediately release the trigger and stop advancing the needle when there is no resistance.
Seeing the needle remaining upright without support is the first sign of proper needle placement.
Remove the cap and the stylet attaches pre-flushed extension tubing and aspirate. Free return of blood confirms correct intramedullary placement. Flush the needle with normal saline.
Assist the physician to instill anesthesia intramedullary, wait for one minute and flush the IV line.
Begin the infusion.
Wrap the sterile gauze about the needle entry site and securely tape in one place.
Discard the waste as per JMMCRI policy.
Doff gloves & perform hand hygiene.
Record the procedure in nurse’s record including site and amount of fluid infused.

CARE OF INTRAOSSEOUS CANNULA

NURSING ACTION	RATIONALE
Secure intraosseous cannula in place.
Attach a 3-way extension cap
Infuse the injections through the 3-way tap side port.
Connect IV fluids through the other 3-way port.
IV fluids will need to be infused under pressure or bolused using 20ml syringe.	Gravity is insufficient to drive the fluid through an IO.
Observe for complications- discoloration of limb, swelling, pain, altered sensation in limb, skin temperature change, weak or absent pulses, limb firmness, or taut compared to the other limb, especially in the first half hour.
Perform hourly neurovascular observation) on the limb from time of insertion during the first 24 hours.
Ambulation should be discouraged until the IO catheter is removed.	To reduce the risk of dislodgement.
Consider using the other limbs for measurement of clinical vital observation.
Document all relevant information in the nurse’s record.

REMOVAL OF INTRAOSSEOUS CANNULA

Monitor insertion site for extravasations and limb for perfusion. Stop infusion.

IO access should not be used for greater than 24 hours. Alternative intravenous access should be obtained as soon as possible.

Remove the extension set from needle hub and attach a 5 to 10 ml sterile syringe with standard leur lock to act as a handle and cap the open IO port.

Grasp syringe and continuously rotate clockwise while gently pulling until the needle is removed.

Maintain 90⁰ to the bone. Do nor rock or bend the needle during removal.

Apply pressure to the site.

Apply sterile occlusive dressing.

Monitor site 4 hourly for delayed sign of infection, hematoma, extravasations or compartment syndrome

Document all relevant information in the nurse’s record.

NM0703a - EYE INSTILLATION

DEFINITION

Administration of ophthalmic medication in to eye in the form of liquids or ointments.

PURPOSE

To treat infection.

To instill medication before examination or surgery of eyes.

To lubricate eyes.

To stain cornea for identifying abrasions and scars.

ARTICLE

• Medical Record

• Medication bottle with dropper

• Bowl small with normal saline

• Cotton-fluff

• Cotton tipped applicator

• Gloves

• Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Identify patient and assess for: • Allergy to medication. • Appearance of eye and surrounding structures. • Lesions, exudates, erythema or swelling. • Location and nature of any discharge. • Level of consciousness and willingness to cooperate • Patient’s knowledge about medication. • Use of contact lens.	Identifies contraindication for instillation of medication into eyes.
Check medication order • Check physician’s order at drug kardex for preparation, strength of medication, number of drops, frequency of instillation of medication and eye to be treated. • Check expiry date and medication label.	Prevents medication error.
Follow ten rights medicine administration.	Facilitate effective medicine administration.
Prepare patient for treatment • Check hospital no. and name. • Explain procedure. • Assist the patient to a comfortable position sitting or lying with head slightly hyper extended. • Obtain assistance for immobilizing in case of young children. • Remove contact lenses, if present.	Reduces anxiety and ensures cooperation. Reduces errors. Prevents accidental injury during medication administration.
Wash hands.	Reduces spread of microorganisms.
Clean eyelid and eyelashes a) Don gloves. b) Use sterile cotton swab immersed in sterile normal saline and wipe from inner canthus to outer canthus.	Cleaning the eye prevents secretions on eyelid and lashes being washed into the eye. Cleaning toward outer canthus prevents contaminants entering into the other eye and lacrimal duct.
Administer eye medication a) Check ophthalmic preparation for name, strength, expiry date and. number of drops in case of liquids. b) Instruct the patient to look up to the ceiling. Give the patient a dry sterile absorbent cotton ball. c) Expose the lower conjunctival sac by placing thumb or fingers of non-dominant hand just below the eyes zygomatic arch and gently draw down the skin on the cheek.	Checking medication prevents medication error. Person is not likely to blink if looking up and in this position the cornea is protected by upper lid. A cotton ball can be used to wipe off excess ointment. Placing finger on the bony prominence avoids pressure to the eyeball and prevents person from blinking or squinting.
Liquid medication a) Discard the first drop of medication. b) Approach the eye from the side and instill the correct number of drops into the outer third of lower conjunctiva, holding the dropper 1-2cm above the eye.	The first drop is considered to be contaminated. Patient is less likely to blink if a side approach is used. If used fall directly on the cornea, it may cause injury.
Eye ointment • Discard the first bead of ointment. • Hold the tube above conjunctiva sac, squeeze 2cm of ointment from tube into lower conjunctival sac from inner canthus outward.
Instruct patient to close eyelid and not to squeeze them out.	Squeezing can injure eye and push out medication.
Instruct patient to press on nasolacrimal duct for at least 30 seconds after instilling liquid medication.	Pressure prevents medication running down the duct.
Clean the eyelid as needed by wiping from inner canthus to outer canthus.	Prevents spread of organisms into lacrimal duct.
Apply an eye pad if required and secure it with tape and instruct patient not to rub the eye.	Reduces risk of injury.
Assess patient response.
Replace medication.	Marinating multi-vial risk policy reduces the risk of contamination of medicine.
Wash hands.	Reduce the transmission of microorganism.
Document administration in drug kardex: medication administered, number of drops, and patient’s response, etc.	Reduces the chances of medication error and gives the professional accountability.

NM0703b - EAR INSTILLATION

DEFINITION

Ear instillation is the process of introducing the otic medication or other medication into the ear canal.

PURPOSE

Ø To soften the ear wax

Ø To provide the local therapy reduce inflammation, destroy infective organisms in the external ear canal

Ø To relieve pain

Ø To facilitate removal of foreign body

ARTICLE

Ø Medical record

Ø Medication bottle with dropper

Ø Cotton-fluff

Ø Cotton tipped applicator

Ø Gloves

Ø Kidney tray

Ø Bowl small with normal saline

PROCEDURE

NURSING ACTION	RATIONALE
Assess for: Ø Allergy to medication. Ø Redness/abrasion in the pinnae/meatus Ø Types and amount of discharge complaints of discomfort. Ø Ability to cooperate. Ø Specific drug action and side effects. Ø Patient’s knowledge about medication to be administered. Ø Expiry date of medicine.	Identifies contraindication for ear instillation.
Check medication order for name, dose, time, amount and ear to be treated.	Reduces risk of medication errors
Identify patient and explain procedure, the purpose of medication and position to assume during and after instillation.	Reduces anxiety and promotes cooperation of patient
Follow ten rights of medicine administration.	Facilitate effective medicine administration.
Obtain assistance in case of children or infants, to immobilize them.	Prevents accidental injury due to sudden movement during the procedure
Assist patient to a side-lying position with ear being treated uppermost.
Clean the pinna of the ear and meatus of ear canal. Using cotton-tipped applicators. Use normal saline, if necessary.	Removes any discharge before instillation
Warm container in hand or by placing it for a short time in warm water.	Promotes patient comfort and prevents vertigo and nausea
Fill ear dropper partially with medication.
Straighten auditory canal. For an infant or child less than 3 years, pull pinna down and back. For an adult or child older than 3 years, pull pinna upward and backward.	Straightening the canal can ensure to flow the entire length of the canal.
Instill correct number of drops alongside of ear canal by holding the dropper one centimeter (1/2 inch) above ear canal.	Reduces trauma to tympanic membrane.
Press gently and firmly a few times on the tragus of the ear.	Pressing on the tragus assists flow of medication into ear canal
Instruct the patient to remain inside-lying position for about 5 minutes.	Prevents drops from escaping and enables medication into ear canal
Insert a small piece of cotton fluff loosely at the meatus of auditory canal for 15-20 minutes.	The cotton helps to retain medication when patient is upright. If pressed too tightly the cotton will interfere with the action of drug and movement of secretion
Assess for patient’s comfort, response and check for discharge/drainage from the ear.
Replace medication and other articles.
Wash hands.	Reduces spread of micro-organism
Document medication administration at drug kardex. Name of medication, number of drops administered and patient’s response.

NM0703c - NOSE INSTILLATION

DEFINITION

Nasal instillation is the process by which a liquid medicine is introduces into the nasal cavity drop-by-drop.

PURPOSE

· To treat allergies

· To treat sinus infection

· To treat nasal congestion

ARTICLE

Medical record

Prepared medication with clean dropper

Pen torch

clean gloves

Facial tissue

Small pillow

Kidney tray

Tissue paper

GENERAL INSTRUCTIONS

§ Medication is instilled only on written order from the doctor.

§ Avoid oil based solutions as nasal drops since it interferes with the normal ciliary action and may cause aspiration pneumonia.

§ Avoid the use of decongestant drops for a long period, because they become ineffective.

§ Administer drugs in correct concentrations.

§ Identify the drug correctly and follow the rules for administration of medication.

§ Medical asepsis should be observed carefully throughout the procedure.

PROCEDURE

NURSING ACTION	RATIONALE
Check physician order at drug kardex · Expiry date of medicine. · Allergy to medication.	Ensures safe and correct administration.
Identify the patient and assess the patient Determines which sinus is affected by referring to medical record.	Ensures the right patient receives the intervention Determines patient’s position during drug instillation.
Assess the patient’s history of hypertension, heart disease, diabetes mellitus and hyperthyroidism.	These conditions can contraindicate use of decongestants that stimulate CNS side effects of transient hypertension, tachycardia, palpitations and headache.
Determine whether patient has any known allergies to nasal instillations.	Prevents complications.
Follow ten rights of medicine administration.	Facilitate effective medicine administration.
Perform hand hygiene.	Prevents cross infections.
Inspect condition of nose and sinuses using pen torch. Palpate sinuses for tenderness.	Provides baseline data to monitor effects of medication. Presence of discharge interferes with medication absorption.
Explain to patient the procedure including positioning and sensations to expect such a burning or stinging of mucosa or choking sensation as medication trickles into throat.	Helps patient anticipate experience of procedure to Reduce anxiety.
Arrange supplies and medication at bedside.	Ensures smooth orderly procedure.
Apply gloves if patient has nasal drainage.	Reduces transmission of micro-organisms.
Instruct patient to clear or blow nose gently unless contra indicated.	Removes mucus and secretion that can block distribution of medication.
Administer nasal Drops a) Assist patient to supine position. b) Position the head properly. -For access to posterior pharynx, tilt patient’s head backward. -For access to ethmoid or sphenoid sinuses, till head back over edge of bed or place small pillow under patient’s shoulder and hyperextend the head. -Support patient’s head with non-dominant hand. -Instruct patient to breathe through mouth. c) Hold dropper 1cm (1/2 inch) above nares and instill prescribed number of drops toward of ethmoid bone. d) Have patient remain in supine position for 5 minutes. e) Offer facial tissue to blot running nose, but caution patient against blowing nose for several minutes.	Position provides access to nasal passages. Position allows medication to drain into affected sinus. Avoids contamination of dropper. Instilling toward ethmoid bone facilitates distribution of medication over nasal mucosa. Prevents premature loss of Medication through nares. Allows maximum amount of medication to be absorbed.
Assist the patient to a comfortable position after medication is absorbed.	Restores comfort.
Dispose off soiled supplies in proper container and perform hand hygiene.	Maintains neat orderly environment and reduces spread of micro-organisms.
Observe patient for onset of side effects 15 to 30 minutes after administration.	Drugs absorbed through mucosa can cause systemic reactions.
Ask if patient is able to breathe through nose after decongestant administration. It may be necessary to have patient occlude one nostril at a time and breathe deeply.	Determines effectiveness of decongestant medication.
Record medication time, concentration, number of drops, nostril into which medication was instilled, time of administration and patient's response drug kardex.	Serves as a communication between the staff members.

NM0704a - VAGINAL SUPPOSITORY

DEFINITION

Introduction of medication into the vagina in the form of creams, jellies, foams, or suppositories

PURPOSES

· To treat/ prevent infections

· To reduce inflammations

· To relieve vaginal discomfort

· To induce labor

· To sustain pregnancy

ARTICLES

· Medical record

· Triangular drape

· Prescribed medication

· Applicator with plunger in case of vaginal cream

· Disposable gloves

· Lubricant

· Towel for wiping perineum

· Mackintosh and towel for placing under buttocks

· Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check medication order at drug kardex and its dosage and time of administration.	Reduce medication errors.
Identify the patient.	Ensure that the right procedure is done on right patient
Assess the patient for •Allergy to medication •Inflammation of external meatus/vagina •Color , character and odor of vaginal discharge •Complaints of vaginal discomfort	Avoids complication
Explain procedure to the patient. Explain that insertion of medication is painless and will bring relief from pain , itching and discomfort	Reduces anxiety and ensure cooperation
Encourage patient to perform procedure herself if she prefers	Provides to comfort of patient and reduces injury to vaginal lining
Instruct patient to empty bowel and bladder	Reduce embarrassment
Provide privacy
Position the patient in dorsal recumbent/ sims position and drape using triangular drape , so that only perineal area is exposed	Reduces embarrassment
Provide perineal wash to remove micro organisms Encourage patient to perform her own perineal wash in toilet if able	Microorganisms. moving into vagina
Administer vaginal suppository; a) Apply cream/foam and lubricate the rounded smooth end of suppository b) Lubricate your gloved index finger c) Expose the vaginal orifice by separating the labia with your non-dominant hand d) Insert suppository about 8-10cm along posterior wall of vagina, or as far as it will go e) The hip may also be elevated on a pillow. If using an applicator, f) Gently insert the applicator about 5cm and slowly push the plunger until applicator is empty g) Remove the applicator and place it on the towel h) Discard applicator if disposable , or clean it according to manufacturer’s instruction i) Request patient to be in a supine position for 5-10 minutes following insertion j) Ensure patient comfort
Dry perineum using towel	Ensures patient comfort
Apply a clean perineal pad if there is excessive drainage
Replace all reusable articles & dispose waste as per JMMCRI policy	Prevents contamination
Remove gloves and wash hands	Reduce risk of transmission of micro-organisms
Document all relevant information in nurse’s record.	Promotes communication between staff members. Ensures patient safety

NM0704b - RECTAL SUPPOSITORY

DEFINITION

Introduction of medication into the rectum in the form of suppository

PURPOSE

· To stimulate peristalsis

· To promote defecation

· To act as analgesic and antipyretic

ARTICLE

v Medical record

v Prescribed medication (suppository)

v Lubricating jelly

v Gloves

v Tissue paper

v Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check physician order.	Ensure correct and safe administration of medication
Assess the patient’s level of activity	Ability for ambulation and follow instruction
Explain the procedure to the patient.	It reveals anxiety and gains co-operation.
Review medical record for history of rectal surgery or bleeding	Identify contra indication
Provide privacy.	Minimize embarrassment in patient
Wash hand and wear gloves	To reduce transfer of microorganism.
Assist patient in assuming left lateral position with upper leg flexed	The position expose anus and help patient to relax to external anal sphincter
Keep the patient draped with only anal area exposed	Maintain privacy and facilitates relaxation
Examine the condition of anus externally and palpate rectal wall as needed	Determine presence of active bleeding, palpation determine whether rectum is filled with feces
Remove suppository from foil wrap and lubricate rounded edge with jelly. Lubricate gloved index finger of dominant hand	Lubrication reduce friction as suppository enters rectal canal
Ask the patient to take slow deep breath via mouth and to relax anal sphincter	Forcing suppository via constricted sphincter cause pain
Retract the buttocks with non-dominant hand and with dominant hand ,insert suppository gently through anus ,past internal sphincter against rectal wall 10cm in adult , 5cm in children and infant	Suppository must be placed against rectal mucosa for eventual absorption and therapeutic action
Withdraw finger and wipe	Provide comfort
Discard gloves turning them inside out and dispose in appropriate receptacle	Reduce transfer of organism
Ask patient to remind flat or on side for 5 minutes	Prevent expulsion of suppository
Check within 5 minutes to determine if suppository is in place. Instruct the patient retain suppository for 30-45 minutes	Re insertion may be necessary if expelled
Discard the waste as per JMMCRI policy	Reduce the contamination.
Discard gloves and wash hands
Document the procedure in the patient’s chart with time, name of medication, dose and patient response

NM0704c - ENEMA

MEANING

Introduction of solution into the colon for removing feces and cleaning the bowl small

PURPOSES

• Relieve constipation or fecal impaction

• Prevent involuntary escape of fecal material during surgical procedure

• Promote visualization of the intestinal tract by radiographic or instrument examination

• Help to establish regular bowel function during a bowel training program

ARTICLES

• Medical record

• Commercially prepared enema

• Water

• Soluble lubricant

• Bed pan and toilet tissue

• Mackintosh/waterproof pad

• Gloves

• Mask

• Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician order and identify the patient.	Ensures the right patient receives the intervention.
Assemble articles.	Organization facilitates accurate skill performance.
Provide privacy.	Reduces embarrassment.
Assist patient to left side lying position and place waterproof pad under the patient.	Facilitates flow of solution via gravity in to the rectum and colon.
Wash hands and wear gloves.	Reduce transmission of micro-organism.
Cover the patient exposing only anal; area.	Minimizes unnecessary exposure and promotes the comfort.
Place bed pan in an easily accessible place.	For use in case the patient is unable to retain enema solution.
Remove the cap and lubricate the rectal tube 2 to 3 inches.	The anal canal about 1 to 2 inches.
Separate the buttocks and locate the anus. Ask the patient to take several deep breaths.	Helps for good visualization. Helps to relax the anal sphincter.
Compress the container. Roll the end up on itself, toward the rectal tip. Administer all the solution until the urge to defecate is strong.	Aid to administer all the contents of container.
After the solution has been given, remove the tube, keeping the container compressed.
Encourage the patient to hold the solution until the urge to defecate is strong.	It allows muscle contractions to become sufficient to produce good results.
Return the patient to a comfortable position.	Promotes patient comfort.
Discard the items as per JMMCRI policy.	Reduces the contamination of items.
Remove gloves and perform hand hygiene.	Prevent spread of micro-organisms.
When patient has a strong urge to defecate, assist patient to toilet or help to position on bedpan.
Leave the patient clean and comfortable.
Perform hand hygiene.	Prevents cross infection.
Record the procedure and the characteristics of results.	Continuity in care.

DIGITAL EVACUATION

DEFINITION

Digital evacuation is the use of fingers to manually remove the stool from the rectum.

A single finger of gloved hand is lubricated and inserted into the rectum. The stool is gently broken up and removed in pieces until the rectum is cleared.

INDICATION

· Patients with impaction of feces

· Patients with neurogenic bowel

· If enema fails

EQUIPMENT

¨ Lubricant

¨ Toilet tissue

¨ Mackintosh

¨ Gloves

¨ Kidney tray

¨ Bedpan

PROCEDURE

NURSING ACTION	RATIONALE
Explain the procedure to the patient and the caregiver.	Reduces anxiety and promotes cooperation.
Assemble the needed things.	Saves time.
Provide privacy.
Position patient left lateral position.	For insertion of a finger into the rectum easily.
Cover the patient adequately with sheet and expose only rectal area.	Promotes self-esteem.
Wear the gloves and lubricate index finger of dominant hand with jelly.	Easy insertion of finger into the rectum without injuring the rectal mucosa.
Gently insert gloved finger into the rectum and advance finger slowly along the rectal wall inward.	Reach the feces and to remove it.
Gently loosen the fecal mass by massaging around it.	Promotes the removal of fecal contents.
Bring the feces down toward rectal orifice and remove small pieces and discard into bedpan.	Empties the bowel.
Clean with wipes.	Prevent contamination.
Discard the waste as per JMMCRI policy.	Reduce the risk of transmission of microorganism.
Wash hands with soap and water.	Reduce the risk of contamination.
Replace the article.
Document all relevant information in nurse’s record.	It helps in continuity of care.

NM0705a - NEBULIZATION

DEFINITION

Process of dispersing liquid medication into microscopic particles and delivering into the lungs as patient inhales.

PURPOSE

To administer medication directly into respiratory tract for sputum expectoration.

To reduce difficulty in bringing out thick tenacious respiratory secretions.

To increase vital capacity.

To relieve dyspnea.

ARTICLE

Nebulizer

Medication

O2 with connecting tube

Normal saline

Nebulizer mask

Sputum cup

Disposable gloves

Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check physician’s order.	Avoid medication error from occurring.
Identify patient by name and hospital no.	Ensures that right procedure is done on the right patient.
Explain procedure to the patient.	Gain cooperation and allay anxiety.
Assemble all equipment near bedside.	Organization facilitate accurate skill performance.
Perform hand hygiene.	Promotes infection control.
Position the patient (sitting/semi-fowler’s position) &clean the mask.	Upright position can help expanding the chest.
Monitor the heart rate before and after the treatment for patients using bronchodilator drugs.	Bronchodilator may cause tachycardia palpitations, dizziness or nervousness.
Connect the tubing to the nebulizer. A fine mist from the device should be visible.	Enable deep penetration into tracheobronchial tree.
Place the mask on patient face to cover his mouth and nose and instruct him to inhale deeply and slowly through mouth, hold breath and then exhale several times.	To encourage optimal dispersion of the medication.
Observe expansion of chest to a certain that patient is taking a deep breath.	This will ensure that medication is deposited below the level of oropharynx.
Instruct the patient to breath slowly and deeply until all the medication is nebulized.	Medication will usually be nebulized within 15 minutes.
On completion of the treatment encourage the patient to cough after several deep breath.	The medication may dilate airway facilitating expectoration of secretion.
Observe the patient for any adverse reaction to the treatment.	Patient may develop bronchospasm due to inhalation of secretion.
Discard the waste as per JMMCRI policy.	To reduce spread of microorganisms.
Perform hand hygiene.	Prevents cross infection.
Assist the patient to be in comfortable position.
Document all relevant information in medical record (name of medication, dose, frequency, time, client’s response.	Continuity of care and professional accountability.

NOTE

· It is safe to use oxygen as the driving gas in patients with obstructive airways disease with normal PCO₂.

· Hypoxemia during nebulization with air-driven nebulizers can easily be prevented by simple addition of oxygen source to the air inlet of available nebulizers.

· Nebulizer mask should be cleaned after every use as per JMMCRI policy

NM0706 - ASV ADMINISTRATION

SNAKEBITE

Snakebite is an acute life threatening time limiting emergency. Three major families of venomous snakes are the Elapidae, the Viperidae, and the Colubridae Hydrophidae.

Elapidae (Cobra, King cobra, Krait and Coral snake)

Head and neck has same width.

The head is covered with large scale but lack laureal shields.

There pupils are round and they are oviparaous.

These snakes have grooved fangs that are short, fixed and covered by mucus membrane.

Viperidae (Viper)

Head is triangular wider than the neck and has laureal shields.

They have vertically elliptical pupils and are ovi-viviparous.

Their fangs are long movable and canalised by hypodermic needles.

Factors contributing to severity and outcome in snakebite
Factor	Effect on outcome
Size of victim	Bigger the size, good is the outcome due to less amount of toxin per kg of body weight. Children receive larger envenomation relative to body size.
Comorbidity	Predisposes to harmful effect of snake venom. Elderly victims succumb more easily. Old age, anaemia, hypertension, diabetes mellitus and renal disease.
Part bitten	Patients bitten on the trunk, face, and directly into bloodstream have a worse prognosis.
Exercise	Exertion following snakebite has poor outcome due to enhanced systemic absorption of toxin.
Individual sensitivity	Sensitivity of individual to venom (atopy or previous sensitization) modifies the clinical picture.
Bite characteristics	Bite number, depth of bite, dry bite, bite through clothes, shoes or other protection, amount of venom injected, condition of fangs, and duration for which snake clings to the victim, all affect outcome.
Snake species	Different species have different lethal dose, lethal period, and aggressiveness.
Secondary infection	Presence or absence of pathogenic organisms in the mouth of the snake.
Treatment	Nature of first aid given and time elapsed before first dose of ante venom.
Factors not contributing to outcome are size of the snake and time of bite.

MANAGEMENT OF SNAKE BITE

v Rapid clinical assessment and resuscitation

v Investigations/laboratory tests

v Clinical assessment and species diagnosis, if possible Antivenom treatment

v Observing the response to antivenom

v Deciding whether the further dose(s) of antevenom are needed

v Supportive/ ancillary treatment

v Treatment of the bitten part

v Follow-up

v Rehabilitation

RAPID CLINICAL ASSESSMENT

à Check history of snakebite and look for obvious evidence of a bite (fang puncture marks, bleeding, and swelling of the bitten part). However in krait bite no local marks may be seen. It can be noted by magnifying lens as a pin head bleeding spot with surrounding rash.

à Remove the shoes, watches, rings, jewelry and tight clothing from the bitten area as they can act as tourniquet when swelling occurs.

à Cautiously remove the tourniquet if tied (risk of embolism if used in viper bike).

CLINICAL FEATURES

The signs and symptoms of snake bite follow the four main categories of envenoming

Progressive weakness (neuroparalytic/neurotoxic)

Bleeding (vasculotoxic/ haemotoxic)

Myotoxic

Painful progressive swelling

CLINICAL FEATURES

Asymptomatic cases

Approximately 70% of snakebites are from non-venomous species.

The bite is from a venomous species but has not injected enough venom to cause symptoms or has injected none at all.

The venom is of a sufficiently high level to cause symptoms but is now progressing through the tissue without causing swelling to indicate its presence.

Envenomation take many hours to present signs and symptoms (very common in Krait bite).

The victim may be envenomed but no visible signs or immediately detectable symptoms are visible (the victim may have in-coagulable blood or bleeding or renal failure may be underway but not visible).

Rapid primary clinical assessment and resuscitation:

CABDE approach

Circulation (arterial pulse)

Airway

Breathing (respiratory movement)

Disability of the nervous system (level of consciousness)

Exposure and environmental control (protect from cold)

Early clues that a patient has severe envenoming

Rapid early extension of local swelling from the site of the bite.

Early tender enlargement of local lymph nodes, indicating spread of venom in the lymphatic system.

Early systemic symptoms: collapse (hypotension, shock), nausea, vomiting, diarrhea, severe headache, “heaviness” of the eyelids, inappropriate (pathological), drowsiness or early ptosis/ ophthalmoplegia.

Early spontaneous systemic bleeding

Passage of dark brown/black urine.

Handling tourniquets

Care must be taken when removing the tight tourniquets tied by the victim.

Sudden removal can lead to a massive surge of venom leading to neurological paralysis, hypotension due to vasodilation.

Before removal of the tourniquet, test for the presence of a pulse distal to the tourniquet if the pulse is absent ensure a doctor is present before removal. If the pulse is absent, ensure the presence of a doctor while removing.

In case of venomous envenomation, tourniquet should be removed only after starting of loading dose of ASV in the presence of a doctor.

DIAGNOSIS

Whole blood clotting test (WBCT)

Prothrombin time with INR/clotting time, bleeding time

Platelet count

Clot retraction time

Liver function test

Renal function test

Serum electrolytes (sodium/potassium)

Blood sugar

ECG

Abdominal ultrasound

MANAGEMENT

· Polyvalent Ante snake Venom.

· Two forms

o Lyophilised

o Liquid

· Route of administration is intravenous as slow infusion.

· Epinephrine should always be drawn up in readiness before ASV is administered.

· Inj.hydrocortisone and Inj.avil can be arranged as per the physician order.

DOSAGE OF ASV

The starting dose for;

Neuroparalytic snakebite- ASV 10 vials stat as infusion over 30 minutes followed by 2^nd dose 10 vials after one hour if no improvement within one hour.

Vasculotoxic snakebite- Two regimens of low dose infusion therapy and high dose intermittent bolus therapy can be used.

Low dose infusion therapy – 10 vials over 30 minutes followed by 2 vials every 6 hours as infusion in 100ml normal saline till clotting time normalizes or for 3 days whichever is earlier.

High dose intermittent bolus therapy – 10 vials polyvalent ASV stat over 30 minutes as infusion, followed by 6 vials 6 hourly as bolus therapy till clotting time normalizes and/or local swelling subsides.

Comparison of Lyophilized & Liquid
Long shelf life ( 5years )	Short shelf life ( 2 years )
Requires no cold chain	Requires a cold chain
Speed of reconstitution of 30-60 minutes.	Speed of reconstitution immediate.

MANAGEMENT

If ASV is indicated, signs and symptoms of envenomation with or without evidence of laboratory tests, administer full dose.

There are no absolute contraindications to ASV.

Do not routinely administer ASV to any patient claiming to have beaten by a snake as ASV exposes such patients to the risks of ASV reactions unnecessarily; besides wastage valuables and scarce stocks of ASV.

Do not delay or withhold ASV on the grounds of anaphylactic reaction to a deserving case.

Do not give incomplete dose.

Purely local swelling, even if accompanied by a bite mark from an apparently venomous snake, is not a ground of administering ASV. Swelling, a number of hours old is also not a ground for giving ASV. However, rapid development of swelling indicates bite with envenoming requiring ASV.

WHAT CAN ASV Do and more importantly what can it NOT do?

ASV can

ASV prevents the patient condition from worsening by neutralizing venom that otherwise could have bound a completed its damaging effect on the victim. It does not reverse anything nor does it make the patient better. The latter is the result of the body’s normal functions, such as the liver replacing clotting factors, being able to return to normal by the elimination of the circulating venom.

ASV CANNOT

Reverse necrotic action of the venom on tissue.

Reverse local swelling

Reverse renal failure

Reverse coagulopathy; the liver does this

Reverse pre synaptic envenoming; the nerve damage and large quantities of ASV are ineffective, the body must regenerate synaptic vesicles.

Prevent local necrosis; the damage is done too quickly and the venom is in the tissue and therefore not reachable by the ASV.

Prevent local swelling; the damage is done too quickly and the venom is in the tissue and therefore not reachable by the ASV.

ASV DOSE IN CHILDREN

Children are given exactly the same dose of ASV as adults as snakes inject the same amount of venom into children and adult.

Infusion: liquid or reconstituted ASV is diluted in 5-10 ml/kg body weight of normal saline. However, reduce amount of fluid in running bottle to 200ml to avoid fluid overload.

ANAPHYLACTIC REACTION in ASV administration

Occurs 10-180 minutes of start of therapy

Any new symptoms after starting the ASV drip should be suspected as a reaction to ASV.

Characterized by itching, urticaria, dry cough, nausea, vomiting, abdominal colic, diarrhea, tachycardia, and fever.

Some may develop severe life-threatening anaphylaxis characterized by hypotension, bronchospasm, and angioedema.

Pyrogenic reactions usually develop 1-2 hours after treatment. Symptoms include chills and rigors, fever, and hypotension. These reactions are caused by the contamination of ASV with pyrogens during the manufacturing process.

Late (serum-sickness) develop 1-12 (mean7) days after treatment. Clinical features include fever, nausea, vomiting, diarrhea, itching, recurrent urticaria, arthralgia, myalgia, lymphadenopathy, immune complex with nephritis, and rarely encephalopathy.

FACTORS TO BE REMEMBERED

ASV is available in polyvalent and marketed in liquid or lyophilized preparations in 10ml vial/ ampoule.

Remember to use and maintain cold chain for liquid form. Users are informed to ascertain whether the cold chain is maintained.

There is no dose adjustments.

Before administering ASV, health staff should read and check the status of vial/ ampoule containing ASV.

Elicit history of prior exposure to ASV. If a patient had received ASV earlier and comes back with features of snake envenomation again, he/she has to be considered as a fresh case and treated accordingly. However, care should be taken while administering ASV, since he/she has been sensitized.

ASV treatment should not be initiated without adequate agents for managing anaphylaxis or anaphylactoid reaction.

Anaphylactic or late serum sickness cannot be determined or prevented by test dose. Therefore, do not administer ASV test dose.

ASV neutralizes the unbound venom, hence give it early.

ASV administration should not be delayed or denied on the grounds of anaphylactic reactions to a deserving case.

ASV is required only to those who show definite signs and symptoms of envenomation.

ASV should not be pushed as IV bolus or IM directly. ASV has to be administered slowly as IV infusion in normal saline or glucose water over a period of one hour.

Local administration of ASV near the site of bite has been proven to be ineffective and painful, and raises the intra-compartmental pressure, particularly in the digits. Hence, it should not be adopted.

DANGERS OF VENIPUNCTURE

In patients with in-coagulable blood, any injection (subcutaneous, intramuscular) and particularly venipuncture, carries a risk persistent bleeding and hematoma formation.

Repeated venipuncture can be avoided by using an indwelling cannula and three-way tap system. When the blood coagulability has been restored, the dead space should be filled with heparinized saline, but if this is not flushed out before blood sampling, misleading results will be obtained in clotting tests.

In patients with coagulopathy, sites of venous access and placement of intravenous cannula or catheters should be chosen where hemostasis by external pressure is most likely to be effective, e.g. the antecubital fossa.

If possible, avoid jugular, subclavian, and femoral vein puncture.

A pressure pad may be applied at the site of any venipuncture.

NURSING CARE

Identify the patient

Explain the procedure to the patient and bystanders

Clarify the doubts.

Have the person lie down with wound below the heart.

Keep the person calm and at rest remaining as still as possible to keep venom from spreading.

Cover the wound with loose sterile bandage.

Do not cut a bit wound. Do not apply tourniquet, ice or water. Initiate two large bore IV line.

Do not give the person alcohol or caffeinated drink or any other medication.

Laboratory test (Baseline parameter including coagulation profile, CBC, electrolyte, panel, blood typing, platelet count, D-dimer, urinalysis, metabolic panel and liver panel. Oxygen administration at 2-4 L/min via nasal cannula. Baseline EKG, chest X-ray, ABG.

Clean the bite area with soap and water.

The circumference and characteristics of the extremity should be measured and marked every 15 to 30 minutes to evaluate edema progression. Tetanus booster. (If patient has not had one dose within the last 5 year).

Patient must be observed for at least 8 hours due to the possibility of delayed onset. Anaphylactic reactions as well as serum sickness or delayed hypersensitivity monitored.

Continuous assessment of the patient including vital signs has to be monitored frequently. Antevenom dosing is based on symptoms and titrated until the medication the medication achieves control of local progression and resolves systemic issues.

Administer the prescribed ASV and watch for any complication.

Discard the waste as per JMMCRI policy

Document all the relevant information in the medical record.

NM0707a - PULSE THERAPY

Pulse therapy refers to the administration of a drug intermittently to accelerate the therapeutic efficacy. Pulse therapy also refers to intravenous infusion of high dose of steroids for one or more days for quicker, better efficacy and to decrease the side effects of long term steroids.

INDICATION

Pemphigus

OBJECTIVES

To gain greater efficacy of the drug and fast response

To avoid the need for long term use of systemic steroids

To achieve a steroid sparing effect

PHASES OF PULSE THERAPY

Dexamethasone cyclophosphamide pulse therapy

The DCP therapy is divided in four phases.

Phase 1 therapy includes administration of 100mg of dexamethasone dissolved in500ml of 5% glucose as a slow intravenous drip over 2 hours repeated on 3 consecutive days. On the 2nd day, the patient is also given 500mg of inj.cyclophosphamide in 500ml of 5% dextrose. This constitutes 1 DCP.

During the phase 1 period in addition with DCP therapy 40-60mg of prednisolone/day orally is given to achieve remission which is defined as complete healing of the existing lesions and absence of new lesions. It is also for the patients who is gradually tapered off steroid.

During the phase 2 periods, the patient remains completely alright clinically but receives 9 more DCPs at exactly 28-day cycles along with 50mg Cyclophosphamide orally.

During the phase 3 periods is composed of complete withdrawal of DCP. During this phase patient receives only 50mg Cyclophosphamide orally/ day for the next 9 months.

During the phase 4 therapies includes stoppage of all treatment of pemphigus and the patient is followed up for the next 10 years to look for a relapse.

PRECAUTIONS BEFORE ADMINISTRATION OF PULSE THERAPY

Before each pulse

Patient should be free from systemic infections

Control of blood pressure

Complete blood count, urine analysis, electrocardiogram, renal function tests, liver function tests, serum electrolytes should be routinely done

Cardiac assessment is required for all patients.

Precautions during and after pulse therapy

Pulse rate, respiratory rate and blood pressure must be monitored every 15-30 minutes.

Infusion must be discontinued in case of precipitation of an arrhythmia.

Routine checkup of blood sugar level and electrolyte is required.

NM0708a - BIOLOGICAL THERAPY (RITUXIMAB)

Rituximab is a genetically engineered chimeric murine/ human monoclonal IgG, specific for CD20 surface marker on B cells.

INDICATION

Granulomatosis with polyangitis

Non-hodgkin lymphoma

Chronic lypmhocytic leukemia.

Pemphigus vulgaris.

CONTRA-INDICATION

Hypersensitivity to any component, murine protein.

WARNING AND PRECAUTION

Infection: Withhold infusion

Cardiac arrythmias and angina: Discontinue infusion

Bowel obstruction and perforation: Evaluate the abdominal pain, vomiting, or related symptoms.

Live virus vaccines: Do not administer live virus vaccines prior or during Rituximab treatment.

ADVERSE EFECTS

Upper respiratory tract infection

Nasopharyngitis

Urinary tract infection

Bronchitis

Nausea and diarrhea

Headache

Muscle spasms

Anemia

Peripheral edema

PRE-INFUSION CHECKLIST

Tuberculosis screening

Verify that latent tuberculosis infection screening has been performed.

Detailed history of patient tuberculosis exposure risk factors

Hepatitis B screening

Verify negative hepatitis B screening.

Ask patient if he/she:

Is taking any antibiotics

Has any upcoming surgeries.

Has a history of asthma

Is taking anti-hypertensive medication

Is pregnant or breastfeeding

Has recently received vaccine/live vaccine prior to initiating Rituximab.

MEDICATION PREPARATION

Use appropriate aseptic technique

Clean the port of the 500ml IV bag of 0.9% sodium chloride or 5% dextrose in water with an alcohol wipe.

Remove 100ml of 0.9% sodium chloride or 5% dextrose in water, and discard, leaving 400ml in the IV.

Remove cap from Rituximab vial and clean rubber stopper with alcohol wipe.

Carefully withdraw 50ml (500 mg) from 2 vials of Rituximab, for a total of 100ml. Gentle air injection or push-pull method can be used to ease the withdrawal of Rituximab. Discard any unused portion of Rituximab.

Dilute the 100ml (1000mg) of Rituximab into the 400ml of normal saline, yielding a final total volume of 500ml and a final concentration of 2 mg/ml.

Remove the needle.

Gently invert IV bag to mix. Do not shake. Inspect for particulate matter and/or discoloration. Label IV bag with patient's name, drug, dose, and date.

Diluted Rituximab solution may be stored at 2-8 ⁰Cfor up to 24 hours. Protect solution from direct sunlight.

Connect an infusion set with Rituximab. Prime the line.

Rituximab should not be infused concomitantly in the same line with other medications. An infusion pump can help regulate the administration and dosage of the drug.

MEDICATION ADMINISTRATION AND MONITORING

Do not administer as an intravenous push or bolus.

Should be administered in intensive care unit.

Rituximab as (375mg/m²) administered as an IV infusion, once weekly either for singly or combined with other chemotherapy regimens is the dosage recommended for NHL. The other recommended dosage is 1000mg given at the interval of two weeks apart.

First infusion (day 1): initiate infusion at a rate of 8 drops/min, in the absence of infusion reaction, increase infusion rate by 4 drops/min increments every 30 minutes, to a maximum of 20 drops/min. Increase the flow rate by 10 drops/min/hr. till 40 drops and continue the infusion until it completes.

Subsequent infusions: if the patient did not tolerate the first infusion well, start at the same rate as the first infusion (50mg/hr) and follow directions noted above.

If the patient tolerated the first infusion, initiate subsequent infusions at a rate of 10 drops/min in the absence of infusion reaction, increase rate by 5 drops/min increments at 30-minute intervals, to a maximum of 48-50 drops/min..

Interrupt the infusion or slow the infusion rate for infusion reactions. Continue the infusion rate at one-half the previous rate upon the improvement of symptoms.

Push 20cc NS flush into bag once bag is nearly empty to clear all medication in the IV tubing.

Total minimum infusion time for the first infusion is 6-8 hours, plus 15 minutes for the fresh.

Total minimum infusion time for subsequent infusions is 6 hours and 15 minutes for the flush.

VITAL SIGNS

Obtain vital signs (temperature, blood pressure and pulse) upon arrival after starting of medication, every 30 minutes upon discontinuing infusion and before the patient depart the facility prior history of acute infusion reaction, monitor vital signs every 10 minutes for 30minutes then every 30 minutes and for 30 minutes after infusion.

MANAGE ACUTE INFUSION REACTION

Observe for flushing, chills, and rigors slow down the infusion rate and assess the patient for symptom resolution.

Observe for hives, difficulty breathing, chest pain, high or low blood pressure, swelling of hands and face, fever, chills or anaphylaxis, then stop the infusion and treat the acute reaction.

NM0709a - INTRAVESICAL THERAPY

DEFINITION

Intravesical instillation

Intravesical instillation is a procedure by which drugs in solution are slowly introduced into the bladder through a catheter; it triggers an immune response in the mucosa that eventually kills cancer cells. It is commonly used to reduce the likelihood of recurrence of superficial transitional cell cancer of urinary bladder.

Intravesical chemotherapy

Intravesical chemotherapy aims to eradicate any surviving cancer cell in the bladder mucosa and incase of immediate post-operative instillation, to destroy any floating tumor cells left behind by TURBT (Transurethral resection of bladder tumour) and prevent them from implantation.

Examples for chemotherapeutic drugs;

v Doxorubicin

v Mitomycin

v Epirubicin

v Thiotepa

Intravesical immunotherapy

Intravesical immunotherapy aims to eradicate disease by provoking or enhancing the host immune response.BCG (Bacille Calmette-Guerin) installation triggers the immune response in the mucosa that eventually kills tumor cells. Bacteria in the suspension attach to the tumor cells and are absorbed. Consequently immune cells such as granulocytes, macrophages, and lymphocytes move onto the tissue as a part of inflammatory reaction, leading to tumor elimination.

INDICATION

Superficial / Non-muscle transitional cell cancer.

COMMON TREATMENT SCHEDULE

Chemotherapy

One single post-operative instillation, or immediate post-operative instillation followed by 6 doses at weekly intervals followed by 6 more doses at monthly intervals.

BCG

There is no immediate post-operative instillation of BCG. Administration starts two weeks after TURBT and consists of 6 weekly instillation.

DOSAGE

Mitomycin (Mmc)

The most frequent dose is 40mg diluted in40ml NS over 10 minutes. Patient can void only after 3 hours. There is no need hospitalization. No anesthesia is preferred.

BCG

40-120mg diluted in 40ml normal saline.

RISK FACTORS AND EXPOSURE

Exposure during handling may be through

Skin or eye contact

Skin absorption

Inhalation of aerosol and drug particles

Ingestion

Needle stick injuries

ARTICLE

Medical record

Gloves

Antiseptic swab

Dry gauze

Syringe-50cc

Syringe-5cc

Infant feeding catheter (8 F)

Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient by name and hospital number.	Identification reduces the error.
Prior to initial and subsequent administration of intravesical therapy patient should be assessed for overall health status and specific urologic status.	High light any potential risk or complication from the treatment.
BCG should not be prepared in areas where intravenous drugs are prepared.	Chances for infections.
Advise the patient to empty the bladder or use the catheter to drain the urine.	Allow the wall of the bladder to make contact with the intravesical medication.
Advise the patient to clean the area with soap and water.	Prevention of entering micro-microorganism into the bladder.
Arrange the articles near bedside.
Place the patient in A) Female: Dorsal Recumbent Position with legs flexed. B) Male: Supine, thighs slightly abducted.
Perform hand hygiene.
Don gloves.
Introduce the infant feeding tube (IFT) and let it drain the residual urine.
Slowly inject the medication intravesically. Remove the infant feeding catheter.
Be with the patient for 15 minutes.
Encourage the patient to mobilize.
Discard the waste as per JMMCRI policy. (Chemotherapeutic drugs).
Doff the gloves.
Document all relevant information in the nurse’s record.

NM0801a - CANNULATION

DEFINITION

Intravenous cannula is a flexible tube which when inserted into the body is used either to withdraw fluid or inject medication.

Cannula normally comes with a trocar (a trocar pointed needle) attached which allows puncture of the body to get into the intended space.

Intravenous cannulation is a technique that involves the insertion of a fine, flexible hollow tube, with an inner retractable needle, into a peripheral vein. It provides access for the administration of fluids, medication dyes, contrast media and blood products, and enable the removal of blood of blood for analysis.

VEINS TO USE

•Veins in upper extremities

•Basilic or cephalic on the non-dominant side

•Veins with larger diameter

•Veins closer to the skin

•Opposite the surgical site

•Use the distal vein first, proximal to previous site

•Veins that is palpable

•Veins with good capillary refill

VEINS TO AVOID

•Avoid areas where flexion occurs

•Avoid vessels that pulsate

•Small, superficial veins

•Veins close to arteries

•Areas of bruising, infection or inflammation

•Sclerosed veins

•Veins affected by clinical condition

PREFERRED SITES FOR NEONATES

Hand	Dorsal arch veins Cephalic veins
Wrist	Volar aspect Cubital fossa Median antecubital, cephalic and basilic veins
Foot	Dorsal arch Saphenous vein (ankle)
Leg	Saphenous vein (knee)
Scalp	Superficial temporal vein

PURPOSE

To deliver fluids, antibiotics and blood products.

GAUGES OF CANNULA

GAUGES	COLOUR CODE
14G	Orange
16G	Ash
18G	Green
20G	Pink
22G	Blue
24G	Yellow

ARTICLES

· Cannula (size appropriate to the indication for cannulation)

· Syringe

· 0.9% normal saline

· Sterile occlusive dressing

· Sterile gauze

· Alcohol swab

· Tourniquet

· Gloves

· Label

PROCEDURE

NURSING ACTION	RATIONALE
Explain the procedure and win the confidence of the patient.	Explanation reduces anxiety.
Assemble the articles at patient side.	Procedure makes easier.
Perform hand hygiene.	Reduces the spread of microorganism.
Position the arm.	Patient will be in comfortable position.
Check the appropriate vein.
Apply the tourniquet around 4-5 finger widths above the venipuncture site and reexamine the patient.
Don gloves.
Clean the patient’s skin with alcohol wipes from center of venipuncture site to periphery in circular motion to cover an area of 2cm and let it dry.
Remove the needle cover ensuring not to touch the needle.
Stretch the skin distally and inform the patient that they should expect a sharp scratch.
Insert the needle, bevel upwards at about 30 degrees. Advance the needle until a flashback of blood is seen in the hub at the back of the cannula.
Once the flashback of blood is seen, progress the entire cannula a further 2mm and simultaneously withdraw the introducer needle, advancing the rest of the cannula into the vein.
Release the tourniquet, apply pressure to the vein at the tip of the cannula and remove the needle fully.
Flush the cannula with normal saline and observe any changes (resistance, localized tissue swelling) at the insertion site.
Remove the cap from the needle and put this on the end of the cannula.
Carefully dispose of the needle into the puncture proof container.
Apply the dressing to the cannula to fix it in place and ensure that the date sticker has been completed and applied.
Dispose the waste as per JMMCRI policy.
Doff the gloves.
Document in the nurses’ record and IP register.

POTENTIAL COMPLICATION

• Phlebitis

• Cellulitis

• Sepsis

• Tissue necrosis

• Air embolus.

CARE OF CANNULA

ARTICLES

• Syringe of appropriate size

• Normal saline

• Antiseptic swab

• Dry gauze

• Clean gloves

• Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Prepare the article.
Observe the cannula site for any redness, enquire about pain. Observe the dressing that it is secure and the site is visible.	Dressing at the cannula sites are the first line of defense against infection and dislodgement.
Perform hand hygiene and don gloves.
Change the dressing if it became insecure or if there is blood or fluid leakage under the dressing.
Carefully remove old dressing always holding the cannula in place.
Loosen the edge of the dressing/tape and remove low and slow in the direction of hair growth, keeping it close to the skin surface while pulling it back over itself, and supporting the newly exposed skin with the other hand.	Pulling the tape at vertical angle to the skin will pull at the epidermis, increasing the risk of MARSI (medical adhesive related skin injury).
Doff the gloves.
Wash hands and don gloves.
Thoroughly inspect the site of entry of the cannula for any sign of infection.
Clean the skin by alcohol swab for 15 seconds. Use a repeated back-and-forth technique in a spiral motion to clean an area of skin.
Scrub the leur lock plug of the cannula with alcohol swab in a circulatory motion for 15 seconds and let it dry for 30 seconds.
Prepare the flush (minimum 2ml) of normal saline. Use a10ml syringe.	The volume of flush should be equal at least twice the volume of the catheter. Use 10ml syringe for flushing to avoid excessive pressure in the lumen and prevent rupture of the catheter.
Flush the IV line using a pulsatile technique (push pause motion).
Document all relevant information in nurse’s record.

REMOVAL OF CANNULA

ARTICLES

Antiseptic swab

Dry gauze

Adhesive tape

Clean gloves

Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Explain the procedure to the patient.
Arrange the articles.
Perform hand hygiene.
Apply clean gloves.
Loosen tape at the venipuncture site while holding the cannula firmly and applying counter traction to skin.	Movement of the cannula can injure the vein and cause discomfort to the patient counter traction prevents pulling of skin and causing discomfort.
Don clean gloves and holds sterile gauze over venipuncture site.
Withdraw IV cannula/catheter from vein by pulling it along the line of vein.	Pulling along the line of vein will avoid injury.
Apply firm pressure for 2-3 minutes. Hold extremity above the level of heart if bleeding persists.	Prevents bleeding and hematoma formation. Raising limb reduces blood flow to the area.
Examine the catheter removed from patient to see if it is intact. If broken or any part is missing, report it at once to the nurse in charge and physician. If broken piece can be palpated inside the vein, apply a tourniquet above the level of the palpated piece.	If a piece of tubing remains in vein it can travel centrally to heart or lung. Application of tourniquet reduces possibility of the broken piece moving to the heart till physician comes.
Apply sterile gauze piece over venipuncture site with an adhesive tape over it.	Dressing continues to apply pressure over the site.
Discard the articles as per JMMCRI policy. Remove gloves. Perform hand hygiene.	Promoting infection control.
Document all relevant information, in the nurse’s record and IP register.

NM0901a - INTRAVENOUS INFUSION

DEFINITION

Administration of fluid into the bloodstream through an intravenous catheter or butterfly needle inserted into a peripheral vein to replace fluid losses, supply caloric intake or as carrying solution for medications.

PURPOSE

•To administer fluid and electrolytes to maintain the balance within the body.

•To provide glucose necessary for metabolism.

•To provide water-soluble vitamins and minerals.

•To establish a lifeline in case of emergency.

•To administer medications.

•To administer blood and blood products.

TYPES

Isotonic

A solution that exerts the same osmotic pressure as that of blood plasma.

•0.9% sodium chloride solution

•Lactated ringer’s solution

•Dextrose 5% in water (starts as isotonic and then changes to hypotonic when dextrose is metabolized.)

Hypotonic

A solution that exerts less osmotic pressure than that of blood plasma.

•0.45% sodium chloride (half normal saline)

Hypertonic

A solution that exerts a higher osmotic pressure than that of blood plasma.

• D₅ W in half normal saline

•Dextrose 5% saline

•Dextrose 10% saline

•Dextrose 20% saline

•3 % sodium chloride solution

•Hyper alimentation solutions

•Albumin 20%

COMPOSITION OF FLUIDS

Saline solutions

Water & electrolytes (Na+,Cl-)

Dextrose solutions

Water or saline & calories

Lactated Ringer’s solutions

Water & electrolytes (Na+,K+,Cl-,Ca++,lactate)

Balanced isotonic solutions

Varies; water, some calories, electrolytes (Na+,K+,Mg++Cl-,HCO3-)

Parenteral hyper alimentation

` Fluid, electrolytes, amino acids, and calories.

Whole blood and blood components

Plasma expanders- Albumin, Dextran, Hetastarch and Mannitol.

ARTICLES

Ø IV fluid

Ø Infusion set

Ø Syringe 10cc

Ø Normal saline

Ø Antiseptic swab

Ø Dry gauze

Ø Kidney tray

Ø Clean gloves

Ø IV pole

Ø label

PROCEDURE

NURSING ACTION	RATIONALE
Check physician’s order indicating type of solution, amount to be administered ,rate of flow, etc.	Ensures that right procedure is done for right patient.
Identify the patient by name and hospital number. Assess vital signs, skin turgor, bleeding tendencies, disease/injury to extremities, and status of vein.	Obtain baseline data on patient condition.
Follow ten rights of medicine administration.	Facilitate effective medicine administration.
Perform hand hygiene.	Prevents infection.
Open and prepare infusion set a. Check infusion container for sediments, turbidity, and change in color and expiry date. b. Remove tubing from the packet and straighten it out. c. Slide the roller clamp along tubing to just below the drip chamber. Close the clamp. d. Leave the ends of tubing covered with plastic caps until infusion is started.	Reduces risk of complication caused by solution.
Spike the solution container a. Remove protective cover from entry point of the IV bag/ bottle. b. Add any medications if required using syringe and needle. c. Remove cap from the insertion spike. d. Spike the solution container.
Paste a medication label on the solution container if medication was added. Mix the solution. Apply label upside down.	Applying label upside down will help in easy reading when container is hanging. Mixing ensures uniform distribution of the medication.
Paste a timing label on the solution container with date and time when infusion was started and flow rate.	Helps to identify the strating time of the solution.
Hang solution container on the pole. The pole should be adjusted so that solution container is 3 feet (92cm) above patient’s head.	This height is needed to enable gravity to overcome venous pressure and facilitate flow of solution into the vein.
Partially fill the drip chamber by squeezing it till half full.	Prevents air from moving down the tubing.
Prime the tubing a) Release the clamp, and let solution run through the tubing till all air bubbles are removed. Tap tubing if necessary with finger to remove air bubbles sticking on the sides of tubing. b) Disinfect the hub with antiseptic swab for 15 seconds in to and fro motion c) Flush the IV line with normal saline. d) Connect IV tubing to IV cannula and set required drip rate. e) If an infusion pump is used, set it according to the rate prescribed.	Prevents introduction of air into the vein.
Label the IV tubing with date and time of attachment and signature.	Labeling ensures that tubing is changed every 72 hours.
Ensure appropriate infusion flow through pump or by adjusting roller clamp and note patient’s response.
Discard all disposable items, clean and replace reusable items.
Perform hand hygiene.
Document relevant data like date and time of starting IV fluids, amount and type of solution used including medication, flow-rate, type and gauge of needle and patient’s response.
Position patient comfortably.
Assess frequently for swelling, pain, blanching, coolness of surrounding skin, leaking or bleeding from site and change in flow-rate etc.

CHANGING AN INTRAVENUOS CATHETER, TUBING AND DRESSING

PURPOSE

To prevent infection.

To maintain patency of tubing.

ARTICLES

Ø IV fluid bottle/container

Ø IV set

Ø Dry gauze

Ø Antiseptic swab

Ø Adhesive tape

Ø Kidney tray

Ø Gloves

Ø Protective sheet

Ø Label

PROCEDURE

NURSING ACTION	RATIONALE
Obtain the correct solution a. Verify with physician order. Read label of new container. b. Check name of solution, expiry date, constituents and volume present. Check for any sediments turbidity and color change.	Reduces risk of error.
Perform hand hygiene.	Reduces the risk of microorganisms.
Set up intravenous solution by inserting spike of tubing into container. Optional; add medication to IV solution if required.
Apply label to container-including medication added and timing. Prime the tubing with solution. Label the tubing with date and time of changing the tubing.	Communicates the details of medications added and change of tubing.
Dressing a. Open all equipment, swabs, dressing,etc. b. Place protective sheet under extremity. c. Don gloves.	Prevents soiling of bed linen. Prevents contamination.
Loosen the edges of dressing or tape and remove low and slow in the direction of hair growth, keeping it close tot h skin surface while pulling it back over itself ,and supporting the newly exposed skin with other hand	Prevents dislodgements of cannula in case it becomes entangled between layers of dressing.
Discard the dressing in appropriate container.	Prevents contamination.
Assess IV site for infiltration/inflammation. If present remove cannula from the site.	Reduce chance for further trauma to tissues.
Disconnect the used tubing a) Place a sterile gauze piece under the hub of the catheter. b) Clamp the tubing. c) Hold the hub of catheter with non-dominant hand and loosen the tubing with dominant hand using at twisting motion. d) Remove the used IV tubing and place its tip in the kidney tray.	This absorbs any leakage that might occur when tubing is disconnected. Holding the catheter firmly and gently maintains its position in the vein.
Connect the used tubing a) Grasp the new tubing with dominant hand. b) Remove the protective cap at tip and secure it to the hub of cannula or catheter and fix it. c) c. Open the clamp to start free flow of solution.
Remove the tape securing the cannula while holding hub of the needle with one hand.	Prevents inadvertent dislodgement of cannula or catheter.
Clean the skin by alcohol swab for 15 seconds. Use a repeated back and forth technique in a spiral motion to clean the skin.	Cleaning in this manner prevents contamination of IV site from bacteria on the peripheral skin areas. Antiseptic reduces the number of microorganism present thus reducing the risk of infection.
Recap the catheter.	Reduces the risk of displacement and contamination.
Apply sterile gauze over site and fix it with adhesive tape.	Reduces risk of infection.
Label dressing indicating date and time of change and secure IV tubing with additional tapes if required.	Communicate to all staff members about change of dressing and tubing.
Discard all used articles as per the JMMC&RI policy.	Reduces risk of transmission of infection.
Remove gloves and wash hands.	Reduces risk of transmission of infection.
Document all relevant information.	Enables communication between staff members.

DISCONTINUING AN INTRAVENOUS INFUSION

ARTICLE

Ø Sterile gauze piece

Ø Alcohol swab

Ø Adhesive tape

Ø Clean gloves

Ø Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Explain the procedure.	Reduces anxiety and helps in obtaining cooperation.
Wash hands and assemble equipment.	Reduces risk of transmission of micro-organism. Assembling equipment saves time and energy.
Clamp infusion tubing.	Clamping prevents fluid from flowing out of the needle onto the patient or bed when removing.
Hold the IV tubing in non-dominant hand, use the other hand to slide the roller clamp towards the narrow clamp end.
Hold the hub of catheter with non-dominant hand and loosen the tubing with dominant hand using a twisting motion.
Remove the used IV tubing
Cap the cannula.
Discard all disposable articles. Remove gloves.. Discard the waste as per JMMC&RI policy.	Reduces the risk of transmission of microorganism.
Perform hand hygiene
Document all relevant information, (time of discontinuing solution, amount of solution left in the old container if any).	Reduces the chance of medication error and gives the professional accountability.

NM0902a - BLOOD TRANSFUSION

MEANING

Blood transfusion is intravenous administration of blood or its components such as plasma, packed red blood cell, cryoprecipitate or platelets to a patient.

INDICATION

LINICAL CONDITION

Acute anemia

Ø Surgical hemorrhage

Ø Traumatic hemorrhage

Ø Non-surgical/non-trauma hemorrhage

Ø Critical illness

Ø Early sepsis with inadequate oxygen delivery

Ø Septic shock, late sepsis

Ø Acute coronary syndrome with ischemia

Chronic anemia

Ø Chronic blood loss (hepatic disorders, bleeding disorders)

Ø Decreased erythropoiesis (malignancies, chemotherapy, other drugs suppressing bone marrow, renal disorders, nutritional disorders)

ARTICLES

Ø Medical record

Ø Blood or blood components.

Ø A blood transfusion set

Ø 18 G cannula

Ø Syringe with 5ml normal saline -2

Ø Alcohol swab

Ø Adhesive tape

Ø Dry gauze

Ø Tourniquet

Ø Gloves

Ø Kidney tray

Ø IV pole

Ø Label

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician’s order, patient's condition, and history of transfusion/infusion reaction, reason for present transfusion.	Obtain specific data and initiates patient education if required.
Explain the procedure to the patient and relatives and get the written consent.	Gain co-operation.
Check for the blood product, ABO grouping; batch no, date of collection, date of expiry and volume in the blood bag.	Prevent errors in transfusion of blood or blood component.
Identify the patient by name and hospital number.	Right procedure is done for the right patient.
Assist the patient to empty the urinary bladder.	Avoid unnecessary movement in between the procedure.
Assemble the articles near the patient.	Organization facilitates accurate skill performance.
Check the vital signs before starting the transfusion.	Change in vital signs during transfusion may indicate a transfusion reaction.
Perform hand hygiene and wear gloves.	Prevents cross infection.
Insert the cannula, fix well and check the patency with normal saline.	Prevent extravasations.
Double check the blood to be transfused by two staff nurses and fill the name and signature in the forms. Look for any signs of hemolysis, change of color, any clots/leak.	Prevent errors and complications.
Open and prepare transfusion set a. Remove tubing from the packet and straighten it out. b. Slide the roller clamp along tubing to just below the drip chamber. Close the clamp. c. Leave the ends of tubing covered with plastic caps until infusion is started.
Spike the blood bag a. Remove protective cover from entry point of the blood bag. b. Remove cap from the insertion spike. c. Spike the blood bag.
Partially fill the drip chamber by squeezing it till half full.	Prevents air from moving down the tubing.
Prime the tubing a. Release the clamp, and let solution run through the tubing till all air bubbles are removed.tap tubing if necessary with finger to remove air bubbles sticking on the sides of tubing. b. Connect transfusion set to IV cannula and set required drip rate.	Prevents introduction of air into the vein.
Stay with the patient for the first 10-15 minutes	Most of the reaction occur during this time
Continue the follow-up as per the transfusion monitoring record.
Observe for flushing, itching, dyspnoea, rashes or any other adverse reactions. If present, stop the transfusion & report to the doctor	Indication of transfusion reaction
On completion of transfusion, flush the IV line with 5ml normal saline. Make the patient comfortable	Maintains patency
Transfusion monitoring record should be filled and kept as per JMMCRI protocol.
Return the empty bag to the blood centre along with duly filled transfusion reaction form as per JMMCRI protocol
Discard waste as per JMMCRI policy	To reduce the risk of transmission of micro-organism.
Remove and dispose the gloves and wash the hands.
Document all relevant information in nurse’s record in red ink.

NOTES

It is mandatory, whether the reaction occurs or not, to fill the transfusion reaction form and send it to the blood centre on the same day itself.

If reaction occurs along with transfusion reactionform, patient’s urine sample, blood sample(serum,EDTA) drawn from a vein opposite to the transfusion site and remaining blood component with transfusion set should sent back to the blood centre

The only fluids that can be given concurrently through same IV device are normal saline, 5% Albumin, plasma protein fraction or ABO compatible plasma.

Collect one unit of blood at a single time.

DURATION OF TRANSFUSION OF BLOOD COMPONENTS

BLOOD AND BLOOD COMPONENTS	START TRANSFUSION	COMPLETE TRANSFUSION	SHELF LIFE
PRBC	Within 30 minutes of removing blood centre from refrigerator	Completed within 4 hours. Return the unit for discard if this period is exceeded	42 days
PLATELET CONCETRATE	immediately	Within 20 minutes (one unit issued)	5 days
FFP	As soon as possible	Within 30 minutes (one unit)	1 year
CRYOPRECIPITATE	As soon as possible	Transfuse as rapidly as possible	1 year

NM0902b - FACTOR 8 TRANSFUSIONS

Factor 8 is the cofactor of pro-enzyme, respectively acting in the tenase complex, a key mechanism of physiological hemostasis in which a phospholipids –dependent reaction produces the activation of factor 10.

Mutation in the gene encoding for coagulation factor 8 located in the X chromosome are responsible

DOSAGE

Calculated in the basis that 1 unit/kg factor 8 leads to a rise in plasma factor 8 of approximately 2%.

Standard half-life factor 8 products have a half-life of approximately 8-12 hours

NURSING CONSIDERATIONS
Clotting factor concentrates are stored in blood center between 2⁰C - 8⁰C and should not be stored in ward refrigerator.
Occasionally there are slightly more/ less units in the vial may have 513units or 489units. Treat the vial as 500 units and give the total content. Do not discard any product.
No intramuscular injections	Muscles are very vascular and the risk of bleeding and abscess formation is great.
No salicilates / aspirin or products containing aspirin, e.g. NSAIDS.	Causes platelet malfunction and side effects such as gut bleeds.
No invasive procedures without first replacing the missing factor	Includes: removal of sutures, biopsy, and lumbar puncture, dental and all surgical procedures including cautery.
Apply pressure for 3-5 minutes post venipuncture, de-accessing of portcaths and removal of intravenous lines.
Treatment & pain relief should be given promptly and before investigations.	Signs of bleeding may not initially be apparent, but can result in pressure on nerve endings and in joint spaces. The sooner treatment commences and bleeding is arrested, less blood volume will be exerting pressure.

ADMINISTRATION

Factor 8 generally administered as a slow IV push.

Continuous infusion of Factor 8 is indicated for patients requiring admission for severe bleeds or surgical procedures.

NURSING MANAGEMENT

Follow the intravenous administration procedure.

Factor 8 can be administered as slow IV over 15-20 minutes.

Fresh IV line must be initiated.

No other medication can be infused through it.

Pre Normal Saline flushing is mandatory

Monitor anaphylactic reaction.

NURSING CONSIDERATIONS

Reconstitution

Step 1

Remove the plastic cap from the vial.

Wipe the rubber dropper of the vial with an alcohol wipe and allow it to dry.

Step 2

Completely remove the backing from the vial adapter package by peeling back the lid.

Do not remove the vial adapter from the package or touch the inside of the vial adapter.

Step 3

Keep the vial on a flat surface. Hold the vial adapter package with one hand and using the other hand, place the vial adapter over the vial.

The spike should be placed directly above the center of the rubber stopper.

Push the vial adapter straight down until the adapter spike punctures the center of the vial stopper and is fully inserted.

Step 4

Lift the package cover away from the vial adapter and discard the cover.

Step 5

Only use the diluents syringe provided to reconstitute the drug product. Hold the plunger rod at the circular disk. Place the tip of the plunger rod into the end of the syringe. Turn in a clockwise motion until it is securely attached.

Step 6

With one hand, hold the diluents syringe right under the cap, with the cap pointing up. Make sure you are holding the diluents syringe by the ridged part directly under the cap. Do not use if the cap has been removed or is not securely attached.

Step 7

With your other hand, grasp the cap and bend it at a 90⁰ angle until it snaps off. After the cap snaps off, you will see the glass tip of the syringe. Do not touch the glass tip of the syringe or inside of the cap.

Step 8

Be sure the vial is sitting on a flat surface. Insert the tip of the syringe into the adapter opening. Turn the syringe in a clockwise motion until it is securely attached to the adapter.

Step 9

Slowly depress the plunger rod to inject all of the diluents into the vial. The plunger rod may rise slightly after this process.

Step 10

With the syringe still connected to the adapter, gently swirls the vial until the product is completely dissolved. The appearance of the solution should be clear to slightly opalescent and colorless. Do not shake. Do not use the reconstituted medicine if it contains visible particles or is cloudy.

Step 11

Make sure the plunger rod is completely depressed. Turn the vial upside-down. Slowly pull on the plunger rod to draw the solution into the syringe. Be careful not to pull the plunger rod completely out of the syringe.

Step 12

Gently unscrew the syringe from the vial adapter and dispose of the vial with the adapter still attached. Do not touch the syringe tip or the inside of the cap.

POOLING

Pooling is the process of combining two or more reconstituted vials into a larger syringe prior to intravenous administration.

Step 1

Remove the diluents syringe from the vial adapter by turning it counter clockwise until it is completely detached.

Step 2

Leave the vial adapter attached to the vial, as it needed for attaching a large luer-lock syringe. Do not detach the diluents syringe until ready to attach the large luer-lock syringe.

Step 3

Attach a separate, large luer-lock syringe by turning clockwise until it is securely in place.

Step 4

Slowly pull on the plunger rod to draw the solution into the syringe.

Step 5

Repeat this pooling procedure with each vial that is needed to obtain the required dose. When pooling, do not detach the larger luer-lock syringe until ready to attach it to the next vial.

ADMINISTRATION

Inspect the reconstituted solution visually for particulate matter and discoloration prior to administration. Do not use if particulate matter or discoloration is observed.

Do not administer reconstituted medicine in the same tubing or container with other medications.

Steps

Attach the syringe to the connector end of the infusion set tubing by turning clockwise until it is securely in place.

Depress the plunger until all air is removed from the syringe and medicine has reached the end of the infusion set tubing. Do not push solution through the needle.

Remove the protective needle cover from the infusion set tubing.

Perform intravenous bolus infusion. The rate of administration should be determined by the patient’s comfort level, and no faster than 10ml per minute.

Discard the waste as per JMMCRI policy.

Document all relevant information in the nurse’s record.

NM1001a - WOUND DRESSING

DEFINITION

A wound is defined as the discontinuity of the epithelial lining of the skin or mucosa due to physical or thermal damage. The wound should be profusely irrigated with a neutral solution like normal saline to wash off any debris. The use of toxic or irritating solutions like hydrogen peroxide must be avoided as they are detrimental to wound healing.

AIM

To help the wound heal as soon as possible by using an appropriate dressing material to maintain the right amount of moisture.

HOW TO CHOOSE A WOUND DRESSING MATERIAL

When the wound bed is dry use dressing to increase moisture and if too wet and the surrounding skin are macerated, use the material that will absorb excess fluid and protect the surrounding healthy skin.

PURPOSE

Decrease the pain

Apply compression for hemostasis

Protect the wound from the environment

Protect the wound from soiling with body fluids or waste

Immobilize the injured part

Promote wound healing

TYPES OF DRESSING

Semi permeable dressing

• It allows for moisture to evaporate and also reduces pain.

• Acts as barrier to prevent environmental contamination.

• It does not absorb moisture requires regular inspection.

• Requires a secondary dressing to hold the semi-permeable dressing in place.

Tulle

• Tulle is a non-adherent dressing impregnated with paraffin.

• It aids healing but does not absorb exudate.

• It requires a secondary dressing to hold it in place.

• It is ideal for burns as one can use topical antibiotics.

Plastic film dressing

It is known to absorb exudate and can be used for wounds with moderate amount of exudate. It often requires a second dressing.

Hydrogels

These are insoluble and hydrophilic materials that are made from synthetic polymers which have high water content (70- 90%) that helps granulation tissues and epithelium in a moist environment.

It is also decreases the temperature of cutaneous wounds resulting in a soothing and cooling effect. These may be used for dry chronic wounds, pressure ulcers, necrotic wounds and burn wounds. These may produce foul smell due to the bacterial proliferation.

Fixation sheet

It can conform to body contour and provide pain relief and also allow Exudate to escape.

It cannot use in infected wounds.

Calcium alginate dressing

It keeps the wound moist, reduce pain, and can be used pack cavities. It also provide hemostasis and can absorb exudate. It cannot be used in the presence of an infection or on dry wounds. Another dressing is required to hold alginate in place.

Foam dressing

It keeps the wound moist, absorb fluid and protect the wound. They will be painful if they dry out.

Hydrocolloid dressing

It is made up of combination of gel forming materials (carboxymethyl cellulose, gelatin, and pectin) with other agents such as elastomers and adhesives. They can retain moisture and are painless to remove. They are ideal for small abrasions and not to be used on dry or infected wounds.

Paper adhesive dressing

It is useful in approximating wound edges and ideal for small wounds.

TYPE OF WOUND AND DRESSING
WOUND TYPE	DRESSING
Clean abrasion	Use film/ fixation sheet
Soiled abrasions	Dry or tulle dressings, avoid occlusive dressings
Chronic ulcers	Alginate, hydrocolloid or foam
Dry wounds	Moisture retaining dressing like semi permeable colloid.
Infected wounds	Avoid occlusive dressing, can use alginate
Laceration-sutured	Open or dry dressing
Puncture wound	Dry dressing or leave it open avoid dry dressing
Second degree burn (minor)	Film or fixated sheet dressing.
Second degree burn (major)	Medicated tulle or plastic wrap.
Sloughing wound	Moisture returning wound like a hydrocolloid, alginate.

SEVEN STEPS OF WOUND CARE MANAGEMENT

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician’s order	To confirm doctor’
Identify the patient by name and hospital number.	Avoid identity errors.
Explain the procedure and provide privacy.	Facilitates acceptance and compliance with procedure errors.
Assemble articles at the bedside.	Having articles available saves time and facilitates accurate skill performance.
Wash hands.	Reduce the spread of microorganism.
Identify and assess the wound.	It helps to develop a treatment plan.
• Inspect and evaluate the wound by its location, length, width and depth. • Check for undermining. And tunneling of the wound. • Check for the exudates, drainage, color, odor, amount and consistency. • Examine tissue appearance- color and moisture level. o Epithelial tissue-Pink o Granulation tissue-Red o Slough tissue-Yellow o Necrotic tissue-Black • Periwound- is it intact or macerated. • Wound infection. • Presence of bioburden • Edema • Erythema • Warm wound • Odor • Patient fever • Level of pain	It helps to develop a treatment plan.
Cleanse and irrigate the wound, per its assessment. Saline can be used to irrigate the wound.	Removes the loose debris, Exudate, pus and free floating bacteria. Makes the wound easier to see and evaluate.
Protect the periwound by cleaning with normal saline followed by dry skin preparation solution.	Prevent the wound from increasing in size.
Fill the wound with filling material.(gauze, forms, alginates, gels and antimicrobial agent)	It prevents pocket of abscess from forming and promote healing.
Apply a protective dressing.	It helps to provide a clean, moist wound bed and promote granulation, heeling and closure. It also prevents infection.
Apply a secondary dressing. (gauze, conforming stretch bandages, tape, transparent film and composite dressing)	It promotes healing, protect the wound and secure medical devices. It also promotes patient mobility.
Evaluate the wound healing progress (healing/ progressing/ or no change). Also check for new signs of infection, wound dressing staying in place, drainage.
Dispose articles as per JMMCRI policy and perform hand hygiene.	Reduce contamination.
Document all relevant information in nurse’s record.	Reduces the chances of medication error and gives professional accountability.

NM1002a - CARE OF PRESSURE INJURY

DEFINITION

An area of localized soft tissue ischemic necrosis caused by prolonged pressure higher than the capillary pressure with or without shear related to posture which usually occur over a bony prominence.

ETIOLOGY

Pressure of 70 mm Hg applied for longer than 2 hours can produce tissue destruction; healing cannot occur without relieving the pressure.

Friction contributes to pressure injury development by causing abrasion of the stratum corneum.

Shearing force, produced by sliding of adjacent surface, is particularly important in the partial sitting position. This force ruptures capillaries over the sacrum.

Moisture on the skin results in maceration of the epithelium.

AREA SUSCEPTIBLE TO PRESSURE INJURY

· Occiput

· Ear

· Scapula

· Elbow

· Sacrum

· Ischeal Tuberosities

· Greater Trochanter

· Medial Condyle Of Tibia

· Fibular Head

· Medial Malleolus

· Lateral Malleolus

· Heel

RISK FACTORS

• Bowel or bladder incontinence.

• Malnourishment or significant weight loss

• Edema, anemia, hypoxia, or hypotension

• Neurologic impairment or immobility

• Altered mental status, including delirium or dementia

FREQUENCY FOR ASSESSING PRESSURE INJURY

All patients are assessed on admission, during internal transfer, and prior to discharge. Followed by second hourly assessment for patients at risk of pressure injury and patient’s with pressure injury.

INTERNATIONAL NPIAP/EPIAP PRESSURE INJURY CLASSIFICATION SYSTEM (NPUAP-National pressure injury advisory panel &EPUAP-European pressure injury advisory panel)

Category/Stage I: Nonblanchable Erythema

Intact skin with nonblanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue

Category/Stage II: Partial Thickness Skin Loss

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Present as a shiny or dry shallow ulcer without slough or bruising.

Category/Stage III: Full Thickness Skin Loss

Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Category/Stage IV: Full Thickness Tissue Loss

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining tunneling. Exposed bone/tendon is visible or directly palpable.

Unstageable: Depth Unknown

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown) and /or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore category/stage cannot be determined.

Suspected Deep Tissue Injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

RISK ASSESSMENT

Risk assessment is based on the following factors;

Activity/mobility

Perfusion and oxygenation

Nutritional status

Skin moisture

Increased body temperature

Advanced age

Sensory perception

NURSING CARE

Prevent pressure injury development

• Provide meticulous care and positioning for immobile patients.

• Inspect skin several times daily

• Wash skin with normal saline.

• Lubricate skin with a bland lotion.

• Do not apply heating devices directly on skin surfaces.

• Consider using silk-like fabrics rather than cotton or cotton-blend fabrics to reduce the shear and friction.

• Provide wrinkle free bed

• Remove wet linen and damped clothes whenever necessary.

• Avoid food particles or other dust from the bed immediately.

• Implement bowel and bladder programs to prevent incontinence.

• Encourage ambulation and exercise.

• Promote nutritious diet with optimal protein, vitamin and iron.

• Encourage patient to take adequate fluids for hydration.

Relieve the pressure

• Avoid elevation of head of bed greater than 30 degree.

• Reposition every two hours.

• Use special devices to cushion specific area.

• These devices should not be used to elevate the heels (cutout, ring or donut type devices, intravenous fluid bags and water-filled gloves.)

• Use an alternating –pressure mattress or air-fluidized bed for patients at high risk to prevent or treat pressure injury

• Provide for activity and ambulation as much as possible

• Advise frequent shifting of weight and occasional training of buttocks off chair while sitting

Clean and debride the wound

• Use normal saline for cleaning and disinfecting wound

• Apply wet-to- dry dressings or enzyme ointments as directed or assist with surgical debridement

Treat local infection

Apply topical antibiotics to locally infected pressure injury as prescribed

Cover the wound

• Cover the wound with protective dressing as this minimizes disruption of migrating fibroblasts and epithelial cells results in a moist, nutrient –rich environment for healing to occur.

BACK MASSAGE

MEANING

Scientific form of massaging the back using different massaging strokes to provide cutaneous stimulation and thus promotes comfort

PURPOSES

To promote patient comfort

To improve circulation

To prevent bed sore

To provide an opportunity for nurse to inspect skin

To alleviate pain

To improve sleep quality

ARTICLES

Lubricant

Towel

Clean gloves

PROCEDURE

NURSING ACTION	RATIONALE
Identify and assess the need of the patient	To assess the sufficient condition on the client
Perform hand hygiene and wear gloves	Prevents spread of microorganisms.
Explain the procedure to the patient	Gain co-operation
Position( prone/side lying) the patient and provide privacy	To make him/her more comfortable and provide the care easily
Drape the patient as needed	Provide privacy and warmth
Take lubricant/lotion into hand and apply to patient’s shoulders, Back and sacral area	Don’t apply oil or lotion directly to the back skin. Too much application may bring irritation and discomfort
Observe skin and reddened areas. pay attention to skin over bony prominence	To find any abnormalities and pressure injury at the earliest.
Apply hands first to sacral area massaging in circular motion. Stoke upward from buttocks to shoulders. Massage over scapulae with smooth stroke from upper back to arm and laterally alongside of back, down to iliac crests. Do not take the hands off from patient’s back till the end of the procedure(effleurage)(3 min)	Gently, firm pressure applied to all muscle groups promotes relaxation. Continuous contact with skin surface is soothing and stimulates circulation to tissues
Knead skin by gently grasping tissue between your thumb and fingers, knead upward along one side of spine from buttocks to shoulders and around nape of the neck, knead downwards towards sacrum, repeat along the other side of back (petrissage)	Kneading increases circulation. kneading motion is soothing and relieving
Perform tapotment (tapping movement with medical aspects of hands on side of spine from sacral region upwards) for 2 minutes	Provides relaxation to back muscle
End massage with long, stroking movement for an additional 3 minutes and tell patient you are ending massage.	Long stroking is most soothing
If lying on side, ask patient to turn to opposite side and massage other hip
Apply oil or lubricant to back as required	Helps to reduce friction
Wipe excess lubricant from patients back with bath towel/tissues. Assist the patient to wear clothing. Helps patient to comfortable position. Raise side rails as needed, lower bed and open curtains	Excess lotion can act as irritant and soil sheets. comfortable position enhances back rub’s effects
Dispose the articles as per JMMCRI policy d wash and perform hand hygiene.	Promotes infection control.
Document response to massage and condition of skin in nurse’s record.	Documentation provides coordination of care.

POSITIONS TO PREVENT PRESSURE INJURY

SUPINE POSITION

à Place a wedge pillow to support head and shoulder to offload occiput.

à Position each upper extremities either at a 60⁰ angle with pillow support or at a

90⁰ angle to the wedge pillow.

à Plan 2 pillows both below and above the sacrum to offload the pressure.

à Use a bolster pillow to relieve pressure on heels.

à If the knees are hyper extended use a towel roll below each knee.

à Place 1 or 2 bolster pillows against feet to position it correctly.

SEMI SUPINE POSITION

à Tilt the patient to a 30⁰ angle and support their back with a wedge pillow.

à Pull the lower shoulder and lower side of the hip forward to relieve pressure in those areas.

à Place a wedge pillow below head and shoulder to provide support and offload occiput.

à Place lower hand 90⁰ abducted and extending rotated.

à Lower extremities must be flexed, a bolster pillow should be placed between the knees with the upper leg resting over the bolster.it will help to prevent knee injuries related to friction.

à Place a towel roll beneath the lateral malleolus of the lower leg to alleviate pressure.

à Place a pillow between the upper arm and body to prevent friction injury.

PRONE POSITION

à The head of the patient in prone position should be tilted to one side and the upper extremities should be place in 90⁰ abducted and externally rotated position.

à Place a pillow under the head and upper chest for comfort and support.

à Use 2 bolster pillows both below and above the anterior pelvic bone to offload the pressure.it also helps prevent kinking or misplacement of tubing in catheterized patients.

à Put another bolster pillow between knees and ankles for support.

à Place a towel roll between ankles and bolster pillow. The toes will remain untouched on the bed.

3/4TH PRONE POSITION

à Push lower shoulder and lower part of hip backward to relieve pressure. Lower extremities must be flexed.

à Place a wedge pillow to support the head and shoulder.

à Place a pillow between upper arm and body to provide support and prevent injury.

à Keep a bolster pillow under the upper leg.

à Place a towel roll under the ankle of lower leg to alleviate pressure on the lateral malleolus.

SITTING POSITION

à Instruct the patient to alternatively touch the floor on each side for 30 seconds in every 20 minutes. This can help relieve pressure on the ischial tuberosity and sacrum on each respective side.

à Instruct the patient to place left leg over right leg and bend to the right side for

30 seconds and then vice versa.

à Instruct the patient to try to touch the floor in front of them for 30 seconds.

This will help to relieve pressure on sacrum and ischial tuberosity.

NM1101a - HOT WATER BAG

DEFINITION

Local application of dry heat to a specific body part for a short duration using a rubber bag

PURPOSES

To stimulate circulation by dilating blood vessels

To relieve pain, inflammation or muscle spasm

To provide warmth and comfort to patient

ARTICLES

Hot water bag with cover

Boiled water 140⁰F-160⁰F for adult, 120⁰F-130⁰F for children

Mug –to pour water into the bag

Duster

Towel/flannel cover

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient and check the medical record for any special consideration	Right procedure is done for the right patient
Provide explanation to the patient regarding the procedure and the care to be taken	Knowledge about the care during bag application will help prevent accidental burn injury
Assess for the presence of lotion or all over skin surface at the site of application	Heat can be retained with the presence of these products and lead to increased risk of heat of heat intolerance and burns
Perform hand hygiene.	Prevents chances of infection
Fill the hot water bag with hot water, secure the cap and turn it upside down.	Ensure that there are no leaks and pre-warms the bag
Empty the bag and refill with 2/3rd full and remove air by placing it in flat surface	Fill to 2/3rd level ensures comfort hot water to about when applied. When air is removed the bag is easier to move over the body part
Screw the cap tightly, dry outside of the bag using duster and check it for any leakage	Prevents chances of scalding
Wipe off any moisture on the outside of the bag	Moisture on the outside of bag increases risk of Burn
Put on the cover and take to the bedside. If cover is not available, use a pillow case or towel/flannel cover	Use of bag directly over the skin can cause burns. Thick covers can reduce effect of hot application
Apply hot water bag to the area
Remove the bag after 5-10 minutes avoids chances of burn injury	Keeping the bag for 5-10 minutes avoids chances of burn injury
Check the site for redness, blisters, etc. if present apply Vaseline/oil and report it.	Vaseline/oil soothes the skin
Make patient comfortable in bed
Replace articles and perform hand hygiene	Prevents cross infection
Record the time applied , type of water ,purpose of application, reaction of patient and outcome of application in nurse’s record with signature	Provides continuity in care. Giving signature adds professional accountability

Special consideration

1. Do not leave unattended with hot water bag applies /in place

2. Do not apply hot water bottles to patients

a) Who are unconsciousness

b) Whose sensory nerves are not functioning

c) Patient on spinal anesthesia

d) Paralyzed patient

e) Diabetic patients

f) Children

g) Old people

NM1101b - TEPID SPONGE

MEANING

Sponging of body with tepid (tap) water for reducing body temperature

PURPOSE

To reduce body temperature when fever in itself may be deleterious

ARTICLE

o Bath basin

o Tepid water

o Blanket

o Bath towel-2

o Wash cloth-6

o Long mackintosh

o Article for cold compress and ice cap

PROCEDURE

NURSING ACTION	RATIONALE
Assess patient’s body temperature and pulse rate.	Provides baseline for evaluating response to therapy. Sudden temperature change may alter pulse rate.
Explain the procedure to the patient.	Procedure can be comfortable because of cold application. Anxiety over procedure can increase body temperature.
Ensure privacy. Perform hand hygiene and wear gloves.	Prevents cross contamination.
Place mackintosh under patient and remove clothing.	Mackintosh prevents soiling of bed linen. Removing clothing provides access to all surfaces.
Keeps the blanket over body parts not being sponged. Close the windows and door, and put off fan.	Prevents chilling.
Immerse wash cloths in water and apply wet clothes in each axilla and over groin.
Cover one extremity with wet towel.	Axilla and groin contain large superficial blood vessels.
Wet a wash cloth and wipe down towards outer aspect of each extremity and move up from the inner aspect.	Produces heat loss.
Follow a clockwise sequence for wiping the extremities, each in turn for 5 minutes and then the back and the abdomen.	Enhances heat loss through conduction.
Reassess temperature and pulse every 15 minutes.	Prevent sudden temperature fall.
Change water and reapply sponges to axilla and groin as needed.	Water temperature raises as a result of exposure to patient warm body surface.
When the body temperature fall to slightly above normal discontinue procedure.	Prevent temperature drift to subnormal level.
Dry extremities and body part thoroughly.	Prevent chilling.
Dress patient and cover with sheet.	Promotes patient comfort.
Measure body temperature.	Temperature indicate response to therapy.
Record time when the procedure was started and terminated, vital signs changes and patient response.	Provides continuity in patient care and adds professional accountability.

NM1101c - SITZ BATH

MEANING

A procedure where by patient’s perineal area or buttocks are submerged in warm water

PURPOSE

· To relieve pain and discomfort in the perineal area after delivery or surgery.

· To reduce swelling & irritation

· To increase circulation

ARTICLES

· Gloves

· Towel

· Sitz bath basin

· Warm water

· Prescribed medicine

PROCEDURE

NURSING ACTION	RATIONALE
Check physician order.	Right procedure is done for the right patient.
Identify and explain procedure to the patient.	Gain cooperation.
Assess the patient &ability to ambulate to the bathroom.	To assess the tolerance and ability to mobilize.
Gather necessary articles.	For easy access.
Fill the basin with warm water and add the prescribed medicine.	Warm water is soothing and results in vasodilatation to enhance healing.
Keep the basin on a low stool/potty chair in the toilet.
Assist patient to remove the dressing/perineal pad.	To prevent contamination.
Assist patient to sit in sitz bath basin for 15-20 minutes.	Beneficial effects of heat are lost after 20 minutes.
Place a towel on patient thigh.	Promotes warmth and comfort.
Instruct relatives to be with the patient in toilet.	Ensure safety.
Instruct to contract & relax anal sphincter while taking sitz bath.
After 20 minutes assist the patient back to bed and gently dry the area.	To avoid risk of patient fall.
Clean and replace all the reusable articles and wash hands.	Prevents spread of microbes.
Document tolerance of procedure, pain and appearance of perineal area/wound area in nurse’s record.	Provides continuity in care.

NM1102a - STEAM INHALATION

MEANING

Deep breathing of warm and moist air into the lungs for local effect on the air meaning passage or for systemic effect to loosen the secretion.

PURPOSES

To relieve the inflammation and congestion of mucus membranes of the respiratory tract.

To soften thick tenacious mucus which help in its respiratory tract

To aid in absorption of oxygen.

To release spastic conditions of the larynx and bronchi.

To provide antiseptic action on the respiratory tract.

ARTICLES

Nelson inhaler in a small basin/ Electric steam inhaler

Sputum cup

Inhaler mouth piece

Sterile gauze piece

Cotton ball

Towel

Cardiac table

Pillows

Kidney tray

Boiled water

PROCEDURE OF NELSON INHALER

NURSING ACTION	RATIONALE
Check the doctors order and identify patient by name and hospital no.	Right procedure is done for right patient.
Explain the procedure to the patient	Gains cooperation
Warm the inhaler by pouring a little hot water into the inhaler and emptying it after 1 minute. Fill the inhaler with hot water just below the spout.	Reduces loss of heat from inhaler during procedure
Place sterile mouth piece and close the inhaler tightly.	Avoids spillage of hot water or steam
Cover the mouth piece with a gauze piece and plug the spout with a cotton ball	Covering the mouthpiece with a gauze piece will prevent burns of the lips. Cotton balls in the spout will prevent escape of steam
Place a towel around the inhaler and position it in the bowl small	Insulates the inhaler and prevents heat loss
Position the patient(sitting) and switch off fan
Place the apparatus conveniently in front of the patient on the cardiac table with spout opposite to the patient. Remove the cotton plug and discard it into the kidney tray	Keeping the spout opposite to the patient reduce the chances of burns. Removing the cotton plug helps to open spout, so that it can act as an inlet for air
Instruct the patient to place lips on the mouthpiece and deep breath. After removing the lips from the mouthpiece, breathe out air through nose	Directing the steam out through the nostrils relieves the congestion of the mucus membranes of the nostrils
Continue the treatment for 15-20 minutes as long as patient gets the vapors. Observe the patient during the procedure	Helps effectiveness of the procedure
Remove inhaler from the patient after the stated time. Wipe off perspiration from the patients face	Enhances comfort of patient
Give chest physiotherapy and encourage patient to bring out sputum by coughing
Instruct the patient to remain in the bed for 1-2 hours	Reduces chances of dizziness and effects of sudden temperature
Take articles to the utility room, empty the inhaler. Wash it with warm soapy water and then rinse with clean water.	Cleaning of articles avoids contamination and cross-infection
Discard the waste as per JMMCRI policy and perform hand hygiene	Prevents cross contamination
Report time and patient response in nurse’s record	Provides continuity in patient care and adds professional accountability

PROCEDURE FOR ELECTRIC STEAM INHALER

· Make the patient to sit on a chair or on the bed, if not contra-indicated.

· Place the electric steam inhaler on a low table according to the design with the source of steam as close as permissible.

· Plug the electric steam inhaler to the source of electricity.

· Spread a sheet across and over the patient and on the sprout of the steam inhaler.

· Remain with the patient and observe carefully.

· Encourage the patient to remain inside the sheet for about 15-20 minutes, depending on the source and amount of steam.

· Unplug the inhaler once the procedure is completed.

· Wipe the patient thoroughly and keep him/her warm.

· Discard waste as per JMMCRI policy and replace the articles.

· Record all relevant information in the nurse’s record.

NM1103a - MANAGEMENT OF HYPERTHERMIA

Hyperthermia is defined as the elevated body temperature due to break in thermoregulation that arises when a body produces and absorbs more heat than it dissipates. It is a sustained core temperature beyond the normal variance, usually greater than 39⁰C (102⁰F)

CAUSES

Anesthesia

Dehydration

Prolonged exposure hot environment

Illness or trauma

Inability to sweat

Increased metabolic rate

Medication

Vigorous activity

SIGNS AND SYMPTOMS

Body temperature above the normal range

Hot, flushed skin

Increased heart rate

Increased respiratory rate

Loss of appetite

Malaise

Seizures

ASSESSMENT OF HYPERYTHERMIA

Assess for signs of hyperthermia (flushed face, weakness, rash, respiratory distress, tachycardia, malaise, headache and irritability.)

Assess for signs of dehydration (thirst, furrowed tongue, dry lips, dry oral membranes, poor skin turgor, decreased urine output, increased concentration of urine and weak, fast pulse.

Monitor patient heart rate and blood pressure.

Identify the triggering factors for hyperthermia and review the patient’s history.

Identify the triggering factor for hyperthermia and review the patient’s history, diagnosis or procedure

Assess the age and weight. (Extremes of age and weight increases the risk of the inability to control the body temperature).

Accurately measure and document the patient’s temperature every hour or as frequently as indicated, when there is a change in the patient’s condition.

Monitor fluid intake and urine output.

PROCEDURE

NURSING ACTION	RATIONALE
Loosen or remove excess clothing and covers.	Exposing to room air decreases heat and increases evaporative cooling.
Provide hypothermia blankets or cooling blankets.
Provide tepid sponge.	A tepid sponge bath is non-pharmacological measures to allow evaporate cooling.
Apply ice packs to the patient. Cover the ice packs with a towel and regularly adjust the site of application to mitigate skin damage.	Surface cooling by placing ice packs in the groin area, axillae, neck and body is an effective way of cooling
Cold saline is usually infused over 10-20 minutes.	Cooled saline is an effective way to decrease core temperature.
Assist in performing gastric lavage or peritoneal lavage.
Adjust the environmental factors like room temperature and bed linens.
Raise the side rails and lower the bed at all times.
Administer medicine (diazepam) as ordered.
Provide nutritional support.	To meet the increased energy demand and high metabolic rate.
Provide mouth care.	It help to reduce the dryness and cracks caused by dehydration.
Encourage adequate fluid If the patient is alert enough to intake. Provide cool liquids to help lower the body temperature.
Intravenous normal saline infusion can be initiated.	It replenishes fluid losses during shivering chills.
Antipyretics have little effect in hyperthermia.

MANAGEMENT OF HYPOTHERMIA

DEFINITION

Hypothermia is a medical emergency that occurs when the body loss heat faster than it can produce heat, causing a dangerously low body temperature (below 95F/35⁰C).

CAUSES OF HYPOTHERMIA

Pituitary insufficiency

Addison’s disease

Hypothyroidism

Cold temperature exposure

Drowning

Cardiogenic shock

Cirrhosis

Hypovolemic shock

Alcohol

Drug-barbiturates, phenothiazines

Hypoglycemia

Wernick’s encephalopathy.

SIGNS OF HYPOTHERMIA

Shivering

Slurred speech

Slow, shallow breathing

Weak pulse

Lack of coordination

Confusion

Loss of consciousness

Fumbling hands

Infants

Bright red, clod skin

PROCEDURE

NURSING ACTION	RATIONALE
Limit movements to only those that are necessary. Don’t massage or rub the person.	Excessive, vigorous or jarring movements may trigger cardiac arrest.
Move the person to a warm, dry location. Keep him or her in a horizontal position.
Remove the wet clothing. Cut away clothing if necessary to avoid excessive movement.
Cover the person with blankets. Cover the person’s head, leaving only the face exposed.
Insulate the person’s body from the cold ground. Lay the person on his or her back on a blanket or other warm surface.
Monitor breathing. If the breathing has stopped begin CPR if you are trained
If the person is alert and able to swallow, provide a warm, sweet, nonalcoholic, caffeinated beverage.	It helps to warm the body.
Use a first-aid warm compress (plastic fluid filled bag) only to the neck, chest wall or groin.	If heat applied to the arms and legs forces cold blood back toward the heart, lungs and brain it cause to the core body temperature to drop. This can be fatal.
Don’t use the hot bag, a heating pad or heating lamp to warm the person.	The extreme heat can damage the skin, leads to cardiac arrest.
Passive rewarming. Cover the person with heated blanket and offer warm fluids to drink.
Blood rewarming can be done through hemodialysis.
A warmed intravenous solution can be introduced.
Humidified oxygen can be administered with a mask.	It can warm the airways and help raise the temperature of the body.

NM1104a - STOMACH WASH

DEFINITION

Washing out stomach with solution using lavage set.

PURPOSES

•To obtain samples of gastric contents for laboratory studies

•To relieve nausea and vomiting in case of acute dilation of stomach, pyloric stenosis

•To reduce gastric bleeding

•To cleanse stomach as a preparation for surgery

•To remove poisonous or irritating substances from stomach

ARTICLES

§ Medical record

§ Ryle's tube of appropriate size (12-14Fr)

§ Bowl small of water/normal saline/ specific antidotes

§ Pint measure

§ A funnel to attach the NG tube

§ Water soluble lubricant

§ Mouth gag (Oral airway)

§ Suction apparatus

§ Towel

§ Small mackintosh

§ Gloves, Apron , Mask

§ Adhesive plaster

§ Stethoscope

§ Straight scissors

§ Bucket/container for return flow ( Urobag )

§ Syringe

§ Kidney tray

§ Containers for aspirate

SOLUTIONS USED

v Normal saline

v Specific antidotes: if ingested poison is identified (Activated charcoal)

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient and check the chart for physician’s order and any specific instruction	Ensures performance of correct procedure for the right patient
Explain procedure to the patient	Helps in gaining cooperation of the patient
Wash hands and don gloves	Reduces risk of contamination
Remove denture if present and insert a mouth gag	Dentures may cause obstruction, and mouth gag is inserted to prevent biting of the tube
Place the patient in left lateral position	Prevents aspiration of fluid into the lungs
Pass lubricated nasogastric tube slowly and gently to prevent trauma to the tissue	Lubricate the tube makes insertion easy and prevents friction
Ensure proper placement of tube
Secure the tube with adhesive tape	Prevents displacement of the tube
Attach the syringe to the tube and aspirate the gastric contents completely and save it for laboratory analysis
Remove the syringe and attach a funnel to the tube and fill the funnel with irrigating fluid. Raise the funnel to allow fluid to run into the stomach	Ice cold water is used for irrigation when bleeding is present
When two to three funnels of fluid have run into the stomach and before the funnel is completely and before the funnel is empty, pinch the tube, wait for one minute and invert the funnel over a receptacle and allow the fluid to siphon back/aspirate using 50 CC syringe	200ml of fluid is to be introduced at a time to reach all parts of the stomach and inversion of funnel helps in return flow of fluid from stomach
In case of GI bleeding , if blood increases in the outflow, stop the procedure and inform the physician	Prevents further complication
During the procedure observe the patient’s file and degree of consciousness every 15 minutes	Monitors any deterioration in the condition of patient
Lavaging usually requires a total volume of at least 2 liters	Some clinicians advocate use of 5-10 litres of solution
Discontinue the treatment, by pinching the tube and pulling it out quickly	Prevents entry of air into the stomach
Leave the stomach empty at the completion of lavage
Remove gloves and wash hands	Prevents contamination
Give a mouth wash and dry the face	Patient feels comfortable
Replace articles; record the treatment with date, time, amount of solution used, character of return flow and condition of patient before, during and after the procedure.	These give detailed information about the procedure and patient’s response to the procedure
Continue to monitor the patient every 25 to 30 minutes as dictated by his/her condition	Identifies complication at an early stage

CONTRA-INDICATION

· History of corrosive/hydrocarbon/petroleum ingestion

· Seizures

· Unconscious patient

NM1105a - BLADDER WASH

DEFINITION

Flushing out/ Washing of bladder with sterile solution

PURPOSES

· To cleanse the bladder from decomposed urine, bacteria, excess of mucus, pus and blood clots and to maintain the patency of the urinary catheter.

· To relieve congestion and pain in case of inflammatory conditions by the application of heat.

· To promote healing.

· To prevent clot formation in case of bladder surgeries..

· To prevent or treat infections e.g. cystitis.

· To arrest bleeding.

METHODS

Open method;

This method is used to maintain catheter patency and when bladder irrigations are required less frequently. It is usually done using an asepto syringe

Closed method;

This method is used most frequently in patients who have had genitourinary surgery and it can be continuous or intermittent irrigation

ARTICLES

For open method

· Asepto syringe

· Gloves

· Irrigation solution

For closed method

· Sterile irrigating solution

· Antiseptic swabs

· IV stand

· Kidney tray

· Under pad

· Foley’ s catheter

· Catheterization tray

· Blanket/bed sheet

· Sterile syringes

PROCEDURE

NURSING ACTION	RATIONALE
Check physicians order and nursing care plan for type, amount and strength of irrigating fluid and reason for irrigation
Prepare the patient a. Explain the procedure and its purpose to the patient b. Provide for privacy and drape the patient c. empty, measure and record the amount and appearance of urine present in the urine bag.	Clear explanation reduces anxiety Emptying the bag allows for more accurate measurement of urinary output after irrigation
Prepare the equipment a. Wash hands b. Connect the irrigation infusion tubing to the irrigating solution and flush the tubing with solution c. Connect the irrigation tubing to the input port of the 3-way catheter. Connect the drainage port if not already in place.	a. Reduces transmission of micro-organisms b. Flushing the tubing removes air and prevents it from being instilled into the bladder
Irrigate bladder a. Intermittent irrigation - Instill the prescribed amount of irrigant. If specific amount is not ordered, fill up to150ml of irrigant -Clamp the irrigant tubing -If the physician has ordered the irrigant to remain in the bladder, for a measured length of time, clamp the drainage tube and wait for the prescribed length of time -Open the drainage tube and monitor the drainage as it flows into the drainage bag.	The bladder normally feels full when it contains 300ml of urine Some irrigation solutions contain medication and are meant to remain in contact with the bladder wall for a prescribed length of time Assess the drainage for volume, color, clarity and the presence of any clots of debris
Irrigate bladder b. Continuous bladder irrigation -Adjust the clamp on the irrigation tubing to allow the prescribed rate of irrigant to flow into the catheter and bladder -Monitor color, clarity, debris and volume as it flows back into the drainage bag.	Regulates the amount of irrigant flowing in and out of the bladder to prevent distension or damage to any surgical site. Assess for bleeding , clotting, and blocking of urine drainage or other complications
Tape the catheter securely to the thigh	Prevents the catheter from dislodging
Assess the patient condition and tolerance of procedure
Discard all used disposable articles, clean and replace reusable articles
Wash hands	Prevents spread of micro-organisms
Record procedure in nurses record

NM1106a - STOMA CARE

DEFINITION

Maintenance of hygiene by regular emptying of stoma bag and cleaning stoma site

PURPOSE

· Prevent leakage

· Prevent skin excoriation

· Observe stoma and surrounding skin

· Teach patient and relatives about stoma care and the stoma bags

ARTICLES

Tray containing

¨ Rubber sheet

¨ Long sheet

¨ Soap

¨ Disposable colostomy bag

¨ Towel

¨ Gloves

¨ Cotton swabs and gauze pieces

¨ Wash cloth

¨ Water with clamp

¨ Stoma measuring guide

¨ Zinc oxide ointment

¨ Skin barrier

¨ Bedpan

PROCEDURE

NURSING ACTION	RATIONALE
Explain procedure to the patient and explain to him how he has to cooperate	Helps in obtaining cooperation of the patient
Assemble the necessary equipment nearby	Organization facilitates performance of the task
Wash hands and done gloves	Prevents spread of micro-organisms
Provide privacy and assist patient to a comfortable position(fowlers, semi fowlers , standing or sitting position in bathroom)	Positioning allows patient to view the procedure in preparation for learning
Empty the partially filled appliance into the bedpan if it is a drainable pouch	Emptying the contents before removal of the pouch prevents accidental spillage of fecal material. Pouches that are full can detach and leak.
Remove the appliance slowly beginning at the top while keeping the abdominal skin taut. If any resistance is felt, use warm water or adhesive solvent to facilitate removal	Careful removal protects the underlying skin from damage and minimizes discomfort for the patient
Use tissue paper to remove any excess stool from the stoma. Cover stoma with a gauze pad	Gauze absorbs any drainage from the stoma while the skin is being prepared
Gently wash and pat dry the peristomal skin. Mild soap and cleansing agent may be used according to agency policy.
Assess the appearance of peristomal skin and stoma. A moistreddish- pink stoma is considered normal	Change in normal appearance may indicate anemia, altered circulation, and should be informed to physician
Apply paste type skin barrier (zinc oxide) if required and allow the paste to dry for 1-2 minutes	Establishes a smooth surface for application of skin barrier and pouch
Apply the skin barrier and appliance together a. Select size of stoma opening by using the measurement guide b. Trace same size circle on the back at the center of the skin barrier c. Use straight scissors to cut an opening ¼ or 1/8 inch larger than stoma d. Remove the backing to expose sticky side e. Remove gauze pad from covering stoma f. Place better and pouch over the stoma and gently press onto skin while smoothing out creases or wrinkles. Hold the pouch in place for 5 minutes
Instill deodorant in bag if required
Close the pouch if it is drainable by folding the end upward and using a clamp or clip according to manufacturer’s direction	A tightly sealed appliance will not leak and cause embarrassment and discomfort for the patient
Dispose of used equipment, discard gloves and wash hands	Prevents spread of micro-organism
Document appearance of stoma, condition of peristomal skin, and patient’s reaction to procedure	Facilitates continuity of care

EMPTYING COLOSTOMY WITHOUT CHANGING

PROCEDURE

NURSING ACTION	RATIONALE
Empty contents into bedpan or toilet. Rinse pouch with tepid water	Rinsing provides clean appearance and minimizes odor
Wipe the lower 2 inches of the pouch with toilet tissues.	Drying the lower section of the pouch removes additional fecal material
Instill deodorant in bag and uncuff the edge of the pouch and apply the clamp
Document procedure and patient’s reaction to procedure	Ensures communication between staff members

Notes

a) Flatus may cause a pouch to balloon out. This requires immediate attention because if flatus is not released the pouch may separate from the skin barrier causing seepage of fecal contents or release of fecal odor. Open the clamp and release the flatus.( never puncture a hole in the appliance)

b) Measure the patient’s fluid intake and output. Check the stoma appliance for quality and quantity of discharge .record intake and output every 4 hours for the first 3 days of following surgery

c) Stoma site should be always dry. Presence of moisture increases chance for Candida or yeast infection

d) Return of peristalsis causes an increase in flatus. Advice patients that this is indicative of bowel functioning. Also tell them to avoid gas containing food since there is no way to voluntarily control passing of flatus.

NM1107a - CARE OF UNCONSCIOUS PATIENT

DEFINITION

Unconsciousness is generally caused by a temporary or permanent of either the reticular activating system in the brainstem, both cerebral hemispheres and bilateral thalami. During unconsciousness, the patient losses all protective reflexes and sensation and is prone to aspiration and pressure injury.

CAUSES

Structural causes

Stroke

Traumatic brain injury

Intracranial, epidural, subdural hemorrhages

Intracranial tumors

Inflammation

Venous thrombosis

Acute hydrocephalus

Systemic causes

Hypo/hyperglycemia

Hypo/hypernatremia

Hypercalcemia

Seizures

Systemic infection

Meningitis

Encephalitis

Endocrine abnormalities

Drug overdose

Poisoning

Anesthesia

ASSESSMENT

· Assess the airway patency and breathing pattern.

· Assess the responsiveness of the patient by light shaking, painful stimuli to supraorbital ridge, nail beds or temporomandibular joints. If these measures do not produce a response, vigorously pressing the examiner’s knuckles up and down the sternum.

· Assessment of pupils, cranial nerves and motor function will enable to identify the response and prognosis of the patient.

· Assess the Glasgow coma scale to check the level of consciousness of the patient.

Maintain airway

· Place the patient in lateral or semi prone position.

· Raise the head end up to 30⁰-45⁰ to prevent aspiration.

· Suctioning whenever necessary

· Chest physiotherapy

Maintain fluid and electrolyte balance

· Maintain urine output chart and diet chart

· Slow administration of IV fluid and blood as it may increases the intracranial pressure.

· Over hydration and IV fluid with dextrose are always avoided in comatose patient.

· Tube feeding as per the JMMCRI policy.

Provide mouth care

· Emollients to avoid the dryness can be used.

· Protect the patient and maintain the safety.

Maintain skin integrity

· Basic care including bathing, hair care and nail care.

· Care and prevention of pressure injury management as per JMMCRI policy.

· Adequate nutritional and hydration status should be maintained.

· Nail should be kept trimmed.

· Cornea should be kept moist to preserve corneal integrity.

· Provide eye care.

Proper positioning

· Lateral position on a pillow to maintain head in neutral positions.

· Upper arm positioned on a pillow to maintain shoulder alignment.

· Upper leg supported on a pillow to maintain alignment of the hip.

· Change position 2nd hourly.

Self-Care Deficit

· Provide hygienic care of the patient.

· Assess the nails.

· Provide oral hygiene.

· Eye care to reduce the infection.

Nutrition

· The dietary plan is based on the present condition, weight and age of the patient.

Risk for injury

· Side rails must be kept whenever the patient is not receiving direct care.

· Seizure precaution must be taken (Reduce the height of the bed, Fix the side rails, Ensure that the patient is not left alone)

· Adequate support to limbs and head must be given when moving or turning an unconscious patient.

Impaired bowel / bladder habit

· Assess for constipation and bladder distension.

· Auscultate bowel sounds.

· Catheter care must be provided under aseptic techniques.

NM1108a - PRE &POST OPERATIVE CARE

PRE OPERATIVE CARE

Pre- operative assessment is necessary prior to the majority of elective surgical procedures, in order to ensure that the patient is fit to undergo surgery, to highlight issues that the surgical or anesthetic team need to be aware of during the perioperative period, and to ensure patient’s safety during their journey of care.

PURPOSE

v Complete all relevant sections of pre-operative surgical care plan.

v Ensure correct fasting time, intravenous fluid can be administered if needed if fasting time exceeds more than 4 hours.

v Ensure local anesthetic, premedication and regular medication given as required.

v Consider venous thromboembolism prophylaxis complete risk assessment.

v Maintain the fluid electrolyte monitoring.

PHASES

• Pre-operative assessment

• Obtaining informed consent

• Preoperative teaching

• Physical preparation of the patient

• Psychological preparation of the patient.

Pre-Operative Assessment

•Review pre-operative laboratory and diagnostic studies

Complete blood count.

Blood type and cross match

Serum electrolytes

Screening (HIV, Hbs, HCV), VDRL

Urinalysis

Chest X-rays

Electrocardiogram

Other tests related to procedure or client’s medical condition, such as: prothrombin time, partial thromboplastin time, blood urea nitrogen, creatinine, and other radiographic studies.

•Review the client’s health history

Past medical history

Medical conditions (acute/chronic)

Previous hospitalizations

History of any past problem with anesthesia

Allergies

Present medications

Substance use: alcohol, tobaco, drugs,

Review of system

•Assess the physical need

Ability to communicate

Vital signs

Level of consciousness

Confusion

Drowsiness

Unresponsiveness

Weight and height

Ability to move/ambulate

Level of exercise

Prostheses

Circulatory status

•Assess the psychological need

Emotional state

Level of understanding of surgical procedure, preoperative and postoperative instruction

Coping strategies

Support system

•Assess the cultural need

Language need for interpreter

Obtaining informed consent

Ø Surgeon or his/her team explains about the benefits, risk of procedure or surgery.

Ø Patient and witness on behalf of patient must sign the consent form. When the patient is unable to sign or belongs to minor group, a surrogate can sign the consent.

Ø Signature of the doctor and witness on behalf of institution is mandatory in the consent form.

Ø The nurse is responsible for ensuring that all necessary individuals have signed the consent form and that it is in the medical record before patient goes to the operating room.

Pre-operative teaching plan

Pre-operative medication

Post-operative pain control

Discussion of the frequency of assessing vital signs and use of monitoring equipment

Deep breathing and coughing exercises

Use of incentive spirometry

Position changes

Post-operative feeding (naso gastric tube)

PHYSICAL PREPARATION OF THE PATIENT

Nutrition and fluids

Feeding regulation is performed to ensure a well hydrated, energized and fresh patient for surgery. The stomach should be near empty to prevent regurgitation of stomach contents and its aspiration.

For elective surgeries

Solid food

à Solid food can be taken till 10 PM the night before surgery.

à It includes rice, breads, appams with curry and fruits.

Fluids

à Clear oral liquids can be taken till 6 AM.

à It includes clean drinking water, black tea or black coffee etc. sugar or glucose is allowed is a non-diabetic.

à Aerated soft drinks are not allowed.

à Can drink through the night up to 6 AM.

à If the surgery is delayed for any reason, clear liquids are allowed up to 2 hours prior to surgery.

à Thus, I&D s and other procedures done after 12 noon should be encouraged to drink up to 10 AM or even later.

à Particulate drinks like Milk tea, Horlicks or Kanji water are not allowed.

à Breast milk is allowed in a child until 4 AM, which is 4 hours before anesthesia.

à Cow’s milk and infants formulas and other solid foods are permissible up to 6 hours only.

In an emergency, the patient is taken up for anesthesia & surgery 6 hours after the last solid food.

When oral feeding is not allowed for any surgical reason like GI obstruction, IV fluid should be given to maintain adequate hydration and electrolyte balance.

Bowel and bladder elimination

Enema is preferred. It helps to prevent the contamination of the surgical area by fecal matter.

Prior to surgery an indwelling Foley’s catheter may be ordered to ensure that the bladder remains empty.

Hygiene

Patients are advised to take bath one day prior and on the day with antimicrobial soap. It helps to reduce the transient and some residual flora of the skin.

Nail bed is help to detect the cyanosis, so nail polish is asked to remove prior to surgery and cut short the nail.

Pre-operative medications

Regular medications for hypertension, diabetes, arthritis, epilepsy are to be continued on the anesthetist’s advice.

Generally all anti-hypertensive /cardiac medications are allowed except the ACE inhibitors and ARB’s anti-platelet agents like Clopedigrel are stopped.

Pre-anesthetic medications will be prescribed from the “Pre-anesthetic Clinic”. It should be taken on the morning of surgery. The anesthesia may be delayed if pre-anesthetic medicines are not administered on time.

Sleep

Make sure the client get adequate sleep on the previous night of the surgery. It helps to prevent cognitive decline.

Care of valuables

Valuables must be handed over to the relatives before the procedure.

Care of prosthesis

All prosthesis must be removed before the procedure including (partial or complete dentures, contact lenses, artificial eyes, and artificial limbs and eyeglasses, wigs, and false eyelashes must be removed before surgery.

Preparation of skin

Hair removal

Remove hair on or adjacent to the surgical site previous day.

Clean the surgical site with prescribed solution and give time for action.

Safety protocols

Reconfirming the surgery and patient.

Encourage the patient to wear ID band.

Wear sterile gown, cap and mask as per the protocol.

Marking the surgical site.

Pre-operative checklist must be verified.

Recheck consent forms whether it’s duly filled and completed.

Follow the surgical antibiotic prophylaxis, especially duration between the administration of medicine and the time of surgery.

Psychological preparation of the patient

Psychological preparation includes providing three types of information

à Information about the procedure itself.(steps patient must perform and steps health care worker perform)

à The sensations that patient can expect to feel. (sharp, scratch and numbness)

à How to cope with procedure.

BEFORE MOVING TO THEATRE

à Make sure that pre-operative checklist is duly filled.

à Check the pre-anesthetic checkup is done and the ordered are carried out.

à Follow the surgical antibiotic prophylaxis as per JMMCRI policy.

à Patient shall be transferred to operation theatre always either on a wheelchair or stretcher.

à Send all the reports necessary for the surgery along with the patient.

à Document all relevant information in the medical record.

POST OPERATIVE CARE

Post-operative care includes;

Managing pain

Supporting oxygenation &cardiovascular stability

Maintaining fluid balance

Providing wound care

Monitoring bowel function

Assisting with mobility

Preventing complications

POST OPERATIVE PERIOD

OPERATION THEATRE

RECOVERY ROOM

INTENSIVE CARE UNIT WARD/ROOM

DISCHARGE TO HOME

PROCEDURE

Ø Every time the patient is moved, consider the location of surgical incision to prevent further strain on the sutures.

Ø Position should be adjusted in order to prevent obstruction on the drains.

Patient must be moved slowly and carefully during the immediate post-operative care. Moving a patient from one position to another may result serious arterial hypotension after surgery.

Place the patent in lateral position with the neck extended, if not contra-indicated and the arm supported with a pillow. This position promotes chest expansion and facilitates breathing and ventilation.

Ø Side rails should be raised to protect the patient from fall.

Ø Verify patient identity. The nurse must know the type of operative procedure performed and the name of surgeon.

Ø Note the skin color of the patient.

Ø Check the vital signs of the patient. Hourly monitor of temperature to detect hypothermia or hyperthermia. Vital signs must be monitored as it reflects hemodynamic stability and anesthetic reversal.

Ø Encourage patient to take deep breaths. This aerates the lung fully.

Ø Assess and periodically evaluate the patient’s orientation to name or command.

Ø Turn the patient every 1 to 2 hours to facilitate breathing and ventilation.

Ø Monitor intake output chart closely.

Ø Monitor for early symptoms of shock such as cold extremities, decreased urine output (less than 30ml/hr.) slow capillary fill (greater than 3 seconds), dropping blood pressure, and tachycardia.

Ø Monitor and recognize the evidence of fluid and electrolyte imbalance such as nausea and vomiting and body weakness.

Ø Avoid nerve damage and muscle strain by properly supporting and padding pressure injury points.

Ø Maintain NPO status as per the order and assist the patient to return to normal dietary intake gradually at a pace set by patient, (liquid first followed by soft foods and solid foods)

Ø Monitor pain scale. Encourage non-pharmacologic intervention like distraction, relaxations Administer prescribed analgesics.

Ø Record the amount and type of wound drainage.

Ø Regularly inspect dressings and reinforce them if necessary.

Ø Assess for bladder distension and urge to void on patient’s arrival in the ward/ room.

Ø Assist the patient who complaints of not being able to use the bedpan to use a commode or stand or sit to void, unless contraindicated.

Ø Encourage the patient to ambulate as soon as possible. Assess the patient’s feelings of dizziness and his or her blood pressure first in the supine position, after patient sit up, again after patient stands, and 2 to 3 minutes later.

Ø Assist the patient to change position gradually. If the patient become dizzy, return to supine position and delay getting out of bed for several hours.

Ø Initiate and encourage patient to perform bed exercises it improve circulation ( range of motion to arms, hands and fingers, feet and legs; leg flexion and leg lifting; abdominal and gluteal contraction.)

Ø Splint over incision while coughing (hold the pillow firmly over the incision).

Ø Check for signs of airway obstruction (stridor), Signs of atelectasis (decrease breath sounds, SpO2<95% and other indications of respiratory compromise.

Ø Early ambulation helps to improve diaphragmatic excursion with its subsequent decrease in pulmonary atlectasis.

Ø Patients are encouraged to cough and breathe deeply to decrease the pulmonary ventilating defects an improve mobilization of mucous secretions

Ø Apply pressure to sites of active external bleeding.

Ø Apply anti embolism stockings or sequential compression devices.

Ø Administer prophylactic anticoagulants.

Ø Observe the signs of dehiscence and evisceration like increased drainage, opened wound edges and appearance of underlying tissue. /abdominal contents through incision.

Ø Monitor for signs of infection like temperature >100.4⁰F, provide cooling measures,

Ø Post-operative fluid management is dependents on current deficit, maintenance requirements and abnormal losses. In post-operative period, daily maintenance requirement of fluid is between 35-40ml/kg/day due to the higher insensible loss and reduced optimal renal concentrating ability. Electrolyte replacement, after surgery rarely requires more than sodium chloride and potassium supplementation, both at 1mEq/kg/day.

Ø Auscultate for return of bowel sounds. Return of small bowel function occurs within six hours of surgery and is highlighted by return of bowel sounds.

Ø When peristalsis returns advance diet as tolerated.

Ø Check for the signs of post-operative ileus like abdominal distension, absence of bowel sounds, flatus or stool.

Ø Advancement to regular diet should be obtained as soon as the patient condition permits.

Ø Gastric emptying and pyloric sphincter function requires 2 to 3 days. Finally the return of colonic peristalsis that occurs in 3 to 5 days and is signaled by the passage of flatus.

Ø Patients with gastrointestinal dysmotility should be initially kept NPO for 48 hours or until symptoms of nausea resolve. Nasogastric tube can be inserted in continuous vomiting and distension. The tube can be removed once the gastric motility returns.

Ø Clear liquid diet can be initiated and progression to regular diet until full return of gastric motility is confirmed.

Ø Ensure pain controlled prior to scheduled activities that leads to pain. (Ambulation). Adequate pain control allows early ambulation, improved pulmonary toilet, and decreased overall stress.

COMPLICATION

à Shock

à Respiratory Compromise

à Post-Operative Fever

à Oliguria

à Electrolyte and Acid-Base Abnormalities

à Thromboembolic Disease

à Urinary Retention

NM1109a - PRE &POST CARE OF GASTRO PROCEDURE

INTRODUCTION

Gastro procedure allows direct visualization of the interior of GI tract and related structure and is frequently performed to investigate symptoms, confirm diagnosis and offer treatment.

PURPOSE

To diagnose and treat hidden gastrointestinal bleeding.

To detect the cause of malabsorption.

PRE-PROCEDURE CARE

NURSING ACTION	RATIONALE
Identify the patient by hospital number and name.	To make sure that right procedure is done on right patient.
Assure that patient is explained about the procedure by the physician and clarified his/her doubts.
Monitor vital signs, weight, level of consciousness	Body weight helps to calculate the dosage of anesthesia, baseline data helps to patient current status and deterioration in the procedure.
Obtain data about patient present medical status and the medication he is following. Substance abuse, pregnancy, presence any implants like cardiac pacemaker must be identified.	It helps to identify significant health problems.
Check the consent is duly filled.	It is the voluntary agreement of the patient to do the procedure.
Check the consent is signed by the physician and a witness on behalf of the institution.
Review pre-operative laboratory diagnostic study. Complete blood count. Blood type and cross match Serum electrolytes Screening (HIV, Hbs, HCV), VDRL Urinalysis Chest X-rays Electrocardiogram Other tests related to procedure or client’s medical condition, such as: prothrombin time, partial thromboplastin time, blood urea nitrogen, creatinine, and other radiographic studies. USG Abdomen
Initiate NPO from previous night.	It allows a valid examination of GI tract and reduce the risk of vomiting.it is advisable to avoid fibres and seeds before 5-6 days of procedure and bland diet on the day before the procedure.
Initiate Intravenous fluid therapy as per the physician’s order.
Remove all dentures, spectacles and jewellery.	Dentures may lead to aspiration. Metals may tend to burn.
Administer antibiotic prophylaxis if indicated.	Bacteraemia may occurs even during daily activity like brushing and flossing of teeth.
Provide oxygen administration if indicated.
Bowel preparation has to be done from the previous day of surgery. Multiple doses of stimulant laxatives (Oral preparation ) has to be given from the previous day to the day of procedure)	Presence of faeces can reduce the reliability of the test.

POST PROCEDURE CARE

PROCEDURE

NURSING ACTION	RATIONALE
Advise the patient to lie down comfortably for few hours. Maintain right lateral position in liver biopsy.
Restrict the oral intake until gastric reflux return.
Observe for pain, bleeding and other complications.
Obtain a hemogram after 4 hours of procedure to rectify bleeding.
Fluid administration until the patient tolerates orally.	Dehydration due to the use of laxatives and fasting

NM1201a - OXYGEN ADMININSTRATION

MEANING

Administration of oxygen as a medical intervention, which can be for a variety of purposes in both chronic and acute patient care

PURPOSE

· To treat hypoxemia

· To repair tissue oxygenation

· To increase the saturation level

ARTICLES

· Nasal cannula/face mask

· Oxygen tubing

· Oxygen source with flow meter

· Humidifier filled with double de-ionized water

PROCEDURE

NURSING ACTION	RATIONALE
Check physician’s order	Avoid errors
Identify the patient carefully	Ensures that the right procedure is done on right patient
Inspect client for signs and symptoms associated with hypoxia and presence of airway secretions	Left untreated, hypoxia can produce cardiac dysrhythmias and death. Presence of airway secretions decreases effectiveness of oxygen delivery
Explain procedure to patient	Gain co-operation of patient
Ensure no source of fire near patient	Oxygen support combustion and to reduce the risk of fire hazards
Wash hands	Reduce spread of microorganism
Position the patient comfortably	Proper position allows unobstructed oxygen flow and eases the client’s respirations
Attach the oxygen delivery system to oxygen source and adjusted to the prescribed flow rate	Higher rates may cause excess drying of nasal mucosa
Fill the humidifier up to the level marked with double de-ionized water	Filling the water beyond the point will cause water enter into tubing. Humidification prevents drying of the nasal mucosa
Attach nasal cannula/mask to oxygen tubing and connect oxygen tubing to humidifier	Prevents drying of mucus membrane and provide comfort
Place the tip of the cannula into clients nares and face mask over the patient’s nose, mouth and under the chin	Direct flows of oxygen into client’s upper respiratory tract
Adjust elastic head band	To provide comfort for the patient
Initiate oxygen flow.
Stay with patient to observe response	To identify any complication. Anxiety increases the demand for oxygen
Assess the patient comfort and functioning of equipment frequently. Observe client’s nares and superior surface of both ears for skin breakdown	Pressure on ears from cannula tubing or elastic can cause skin irritation
Document the following: date, time, method, flow rate, respiratory condition and response to oxygen	Documentation provides coordination of care. Sometimes oxygen inhalation can bring oxygen intoxication
Check the oxygen setup including the water level in the humidifier. Clean the cannula and assess the client’s nares at least 8 hours	Double de-ionized water needs to be added when the level falls below the line on the humidification container. In long use cases, evaluate for pressure sores over ears, cheeks, and nares

NOTES

Clean the humidifier daily in continuous use, after patient discharge, once in a week if not used.

Put a date of cleaning over the humidifier.

For cleaning

a) Remove the content

b) wash with soap and water

c) Dip in 0.1% sodium hypochlorite solution for 20 min

d) Wash in double distilled water

e) Dry

OXYGEN ADMINISTRATION VIA HOOD

DEFINITION

An oxygen hood is used for babies who can breathe on their own but still need extra oxygen.

ADVANTAGES

Clear plastic shell encloses the baby’s head.

Well tolerated by infants

Allow easy access to chest, trunk and extremities.

Allows control of oxygen delivery

Oxygen concentration

Inspired oxygen, temperature and humidity

Delivers 80-90% of oxygen at 10-15 litre/min

ARTICLE

a. The appropriate size oxygen hood

b. Oxygen tubing

c. Oxygen blender and/or flow meters

d. The humidifier/ heater

e. Double de-ionized water

f. Corrugated tubing

g. The oxygen hood thermometer

h. Oxygen analyzer

i. Pulse oximeter

PROCEDURE

NURSING ACTION	RATIONALE
Check physician’s order. Identify the patient by hospital NUMBER.
Gather all article needed for the procedure
Prepare the patient
Calibrate the oxygen analyzer before assembling the hood.
Head of the analyzer is positioned at the neonates head.
Ensure that there is an emergency oxygen device close by.
Assemble the humidifier and fill the chamber with DD water.
Connect the oxygen blender tubing to the water filled chamber, and also connect the heater tubing to the water filled-chamber.
Place the thermometer inside the oxygen hood in its proper position.	Heater temperature has to be set in 32-37 degree Celsius. Thermometer advances the easy identification of heat variation.
Set up the oxygen hood and blend the air and oxygen to the proper concentration to deliver the desired Fio2.	8—10ltr /min in order to prevent the buildup harmful level of carbon dioxide within the oxygen hood.
Connect the heater tubing to the oxygen hood.
Carefully place the oxygen hood the infant’s head	The infant’s neck seals properly.
Analyze the FiO2 at the infant’s mouth.
Delivered gases directed away from the infant’s face.
Adjust the heater temperature whenever necessary.	To ensure that neutral thermal environment is maintained.
Continue to monitor and assess the patient.
Document the procedure

Continuous monitoring of newborn in a hood.

o FiO2

o Oxygen saturation

o Heart rate

o Respiratory rate

o Temperature inside the oxygen hood

o Double de-ionized water level in the chamber

o Humidification level

o Keep an eye on the infant’s neck area for irritation and skin breakdown.

o Observe that the oxygen hood stays in correct position

o Drain water from the corrugated tubing if any, if necessary

o Monitor infant’s body temperature

o Monitor aware of any complication- hypoxemia, hyperoxemia, hyperthermia, hypothermia and skin breakdown neat the neck

NM1301a - INTUBATION &EXTUBATION

ASSISTING IN INTUBATION

DEFINITION

Assisting in passing of a slender hollow tube into the trachea through nose or mouth using technique to facilitate artificial ventilation and resuscitation.

PURPOSES

o To treat acute respiratory failure, persistent hypoxemia and persistent rise in pCO2.

o To maintain patent airway.

o To ensure adequate oxygenation.

o To provide ventilator assistance when indicated.

INDICATION

o CNS depression

o Neuromuscular disease

o Chest wall injury

o Upper airway obstruction

o Anticipated upper airway obstruction

o Aspiration prophylaxis

o Fracture of cervical vertebrae and spinal cord injury.

ARTICLES

o Stethoscope

o Pulse oximeter

o Suction catheter attached to continuous suction

o Intubation medications (paralytic, sedative. And /or dissociative agent)

o Defibrillator

o Sandbag or towel roll

o Nasal cannula or high-flow nasal cannula

o Bag-valve mask with masks of various sizes and reservoir

o Oral/ nasal airway of various sizes

o Non-rebreather mask

o Supplemental oxygen

o Laryngoscope handle with appropriate size blade

o Laryngoscope blades of various sizes and shape

o Endotracheal tubes of appropriate size

o Malleable Stylet

o Disposable syringes (5cc, 10cc)

o Adhesive tape

o Xylocaine gel

o Laryngeal mask airway

o Magill’s forceps

o Tracheal tube introducer (Bougie).

o Sterile gloves

o Facemask

o Crash cart

PROCEDURE

NURSING ACTION	RATIONALE
Explain procedure to the patient if he or she is conscious. Obtain prior consent from patient or relatives if the procedure is elective. If it is an emergency obtain the consent just before the procedure.	Promotes acceptance of procedure and cooperation for procedure from patient.
Perform an airway evaluation, which includes a history of intubation and difficult intubations.	Patient with restricted cervical motion, obesity and facial or neck trauma may present as difficult airways.
Position the patient in “sniffing position”. This achieved by elevating the patient’s head, extending the head at neck, and aligning the ears horizontally with sternal notch.	It facilitate the best view oral, pharyngeal, laryngeal axes and vocal cords.
Perform an airway evaluation, which includes a history of intubation and extubation.
Check for loose teeth/dentures of foreign body in throat, if so, remove with Magill’s forceps.	Avoids danger of loose teeth or foreign body causing airway obstruction in unconscious patients.
Prepare the medications and saline flush needed and administer as per the order.	Medication minimizes apnea time and allow adequate time for pre-oxygenation.
Pre-oxygenate the patient. Seal mouth and nose with mask and bag-valve mask and initiate bagging with oxygen not less than 3 minutes.	Pre-oxygenation increases alveolar oxygen and decrease alveolar nitrogen tension.
Confirm the light source of the laryngoscope is functioning and the blade is locked in place. Provide laryngoscope to the care giver.
Prepare the endotracheal tube by placing the stylet inside, straightening the tube proximally, and creating a 35⁰angle to the cuff. Inflate the cuff with air via syringe connected to a side port and should be tested for leaks during preparation.
Suction oral cavity.	Provides a clear field of work and prevents aspiration when performing oral tracheal insertion.
Provide lubricated endotracheal tube with stylet in situ.	Facilitates insertion without chances of injury.
Press cricothyroid cartilage with thumb and index finger against esophagus.	Permits clear visualization of oropharynx for insertion.
Assist while endotracheal tube is introduced into trachea and remove stylet.
After the endotracheal tube is passed through the vocal cords, the cuff is inflated using 10cc syringe filled with air.	Prevents chances of tube displacement and aspiration.
Verify placement of tube by auscultating bilateral breath sounds and the absence of breath sounds over the stomach. Also observe for bilateral chest movements.	Confirms tube placement
Arrange post intubation chest X-ray immediately.	It confirms the location of the endotracheal tube’s distal tip 2-4cm proximal to the carina and rules out main stem bronchus intubation.
Connect bag-valve mask with oxygen attached to endotracheal tube and continue bagging.
Insert an oral airway and apply endotracheal suctioning if necessary.
Fix endotracheal tube in position by using adhesive tape. Tube should be fixed at the midline to prevent pressure ulcer at the angle of mouth.	Traditionally, the desired depth from the incisors to the distal tip of the endotracheal tube is 21 and 23 cm in women and men, respectively. The preferred distance appears to correlate more with height than gender.
Connect to ventilator if needed.

POST PROCEDURE CARE

o Place patient in lateral position.

o Arrange for chest X-ray to be taken in order to check placement of ET tube.

o Apply endotracheal suctioning if secretions are present.

o Watch for chest movements, ET tube kinking, obstruction with secretion and blood, leakage of tube cuff, change in position of tube and over inflation of cuff.

o Document type and size of tube used, chest movements, vital signs and patient’s tolerance of procedure.

o Check ABGs periodically.

ASSISTING IN EXTUBATION

TERMINIOLOGY

Weaning

Weaning is a gradual transition from full invasive ventilatory support.

Liberation

Liberation is the complete discontinuation of mechanical ventilation.

Extubation

Extubation is removing an endotracheal tube (ETT), which is the last step in liberating a patient from the mechanical ventilator.

INDICATION

All patients who are on mechanical ventilation for any reason require liberation as soon as possible.

Planning of extubation should start as early as day one of intubation.

EQUIPMENT

All equipment needed for intubation

Bag-valve mask

Equipment for oxygenation post-extubation (nasal cannula, oxygen mask, venturi mask, high-flow oxygen system, continuous positive airway pressure (CPAP)

PREPARATION

Ventilated patients should be assessed daily for readiness to wean.

Screen for any exclusion from initiating liberating pathway.

Spontaneous breathing trial (SBT) is the key to proceed with extubation without delay. The most common weaning parameters to consider initiating the SBT are RSBI ;Rapid shallow breathing index; (respiratory rate/tidal volume) of less than 105,maximal respiratory pressure (MIP) of less than 30cm of water, and minute ventilation of less than10 liters per minute. The duration of the spontaneous breathing trial can be between 30 minutes to 2 hours.

Nocturnal rest with full ventilator support before morning of the trail.

Ensure adequate nutrition.

Avoid excessive intravascular volume.

Ensure appropriate body position with head up and propped up.

Inspect the airways to clean out the inspissated secretions.

PROCEDURE

NURSING ACTION	RATIONALE
After a successful weaning trial/SBT, a decision is made to proceed with extubation.
Position the patient in upright position.
Suction the endotracheal tube and oral cavity.
Remove the endotracheal tube and ask the patient to take a deep breath and exhale.
During exhalation deflate the cuff and takeout the endotracheal tube.
After removing the tube, suction the oral cavity and ask the patient to take a deep breath and cough out all secretions.
Initiate the supplemental oxygen.
Observe the patient continuously.
Suction frequently.	It helps to prevent re-intubation.
Record the time, patient status after extubation
Maintain patient airway. Encourage deep breathing and exercise.
Encourage sitting up position and mobility if no other contraindication exist.

NM1302a - VENTILATOR MANAGEMENT

INTRODUCTION

Ventilation:

The important effect of the ventilation is the removal of carbon dioxide from the body. In a mechanically ventilated patient, the CO2 content of the blood can be modified by changing the tidal volume or the respiratory rate.

Oxygenation

Oxygenation can be achieved by increasing the fraction of inspired oxygen (FiO2%) or the positive end-expiratory pressure (PEEP).

PEEP

The positive pressure that will remain in the airways at the end of the respiratory cycle (end of exhalation) is greater than the atmospheric pressure in mechanically ventilated patient.

Tidal volume

Volume of air moved in and outside the lungs in each respiratory cycle.

FiO2:

Percentage of oxygen in the air mixture that is delivered to the patient.

Flow

Speed in liters per minute at which the ventilator delivers breath.

Compliance

Change in volume divided by change in pressure. In respiratory physiology, the total compliance is a mix of lung and chest wall compliance as these two factors cannot be separated in a patient.

INTRODUCTION

When the diaphragm pushes down the inspiration, negative pressure in the pleural cavity is generated, this in turn creates negative pressure in the airways that suck air into the lungs. This same negative intrathoracic pressure decreases the right atrial pressure (RA) and generates sucking effect on the inferior vena cava

INDICATION

Acute respiratory failure (hypoxic/hypercapnia)

Decreased level of unconsciousness with an inability to protect the airway.

Respiratory distress that failed non-invasive positive pressure ventilation.

Massive hemoptysis

Severe angioedema

Any case of airway compromise such as airway burns, cardiac arrest, and shock.

Surgical procedures.

Neuromuscular disorders.

NURSING ACTION	RATIONALE
Identify the patient by name and hospital number.
Ensure that patient /bystanders are informed about the procedure. Check the consent form is duly signed..
Obtain baseline samples for blood gas determinations (pH, PaO2, PaCo2, HCO3) and chest X-ray.
Establish the ventilator by means of a cuffed endotracheal or tracheostomy tube.	A closed system between the ventilator and patient lower airway is necessary for positive pressure ventilation.
Prepare the ventilator. Set up desired circuitry. Connect the oxygen and compressed air source. Turn on power. Set tidal volume (usually 6- 8mL/kg body weight) Set oxygen concentration. Adjusted according to PaO2. Set ventilator sensitivity. Set rate at 12-14 breaths/minute (variable). Adjust the flow rate (velocity of gas flow during inspiration). Usually set at 40-60L/minute. Depends on rate and tidal volume. Set inspiratory: expiratory (I: E) ratio. Usual I: E ratio is 1:2. Select mode on ventilation. Check machine function: measure tidal volume, rate and I: E ratio analyze oxygen; and check all alarms.	Adjusted according to pH and PaCo2. This setting approximates normal ventilation. These machines settings are subject to change according to the patient’s condition and response, and the ventilator type being used. Check safe function.
Connect the patient airway to the ventilator.	Make sure all connections are secure. Prevent ventilator tubing from pulling on artificial airway, possibly resulting in tube dislodgement or tracheal damage.
Assess patient for adequate chest movement and rate. Note peak airway pressure and PEEP. Adjust gas flow if necessary to provide safe I: E ratio.	Ensures proper function of equipment.
Set airway pressure alarms according to patient’s baseline.
Assess frequently for change in respiratory status by ABGs pulse oximetry, spontaneous rate, and use of accessory muscles, breath sounds, and vital signs. Other means of assessing are through the use of exhaled carbon dioxide.
Monitor and troubleshoot alarm conditions. Ensure appropriate ventilation at all times. Ventilate with resuscitation bag.
Positioning Turn patient from side to side every 2 hours, or more frequently if possible. Lateral turns are desirable; from right semi prone to left semi prone. Sit the patient upright at regular intervals if possible.
Care of endotracheal tube (ETT)/ Tracheostomy Secure positioning of ETT. /Tracheostomy tube with tape or adhesive plaster. Inflate cuff once correct positioning has been confirmed. Cuff is inflated with air using a syringe and cuff pressure is checked by manometry.	Care of ETT/ Tracheostomy
Maintaining ventilation Effects of ventilation are assessed by observing patient’s color, chest movement, blood pressure, pulse rate, oxygen saturation and ventilator measurements such as expired minute and tidal volume, airway pressure and rate of ventilation. Ventilators make characteristic sounds during inspiration and expiration and any deviation from the normal sound must be identified.
Signs of adequate ventilation Improvement in skin color and oxygen saturation more than 90%. Rhythmic expansion of chest, with expiratory phase longer than inspiratory one. Normal pulse. Change in pulse rate indicate decreased cardiac output due to increase in intrathoracic pressure. Steady blood pressure. A drop in blood pressure may reflect decreased cardiac output. Absence of any abnormal neurological signs, audible respiratory rhythm. Absence of hyperventilation or hypoventilation.
Signs of inadequate ventilation Breathing occurs out of sequence with ventilator setting and patient. If changes in recordings of ventilator volume occur, check airway pressure and rate of ventilation. It decrease in airway pressure occurs, check for leak in circuit. It increase in peak airway pressure occurs, check for obstruction If there is decreased air entry on the left, check the placement of ET tube as it may it easily slip into the right bronchus.
Specific care of patient on ventilator Carry out passive range-of motion exercises of all extremities for patients unable to do so. Assess for need of suctioning at least every two hours.	Patients with artificial airways on mechanical ventilation are unable to clear secretions on their own. Suctioning may help to clear secretions and stimulate the cough reflex.
Assess breath sounds every two hours: • Listen with stethoscope to the chest in all lobes bilaterally. • Determine whether breath sounds are present or absent, normal or abnormal, and whether a change has occurred. • Observe the patient’s diaphragmatic excursions and use of accessory muscles of respiration. Auscultation of the chest is a means of assessing airway patency and ventilator distribution.it also confirms the proper placement of the endotracheal or tracheostomy tube.
Humidification Check the water level in the humidification reservoir to ensure that the patient is never ventilated with dry gas. Empty the water that condenses in the delivery and exhalation tubing into a separate receptacle, not into the humidifier. Always wash hands after emptying fluid from ventilator circuitry. Humidification may also be achieved using a moisture enhancer.	Water condensing in the inspiratory tubing may cause increased resistance to gas flow. This may result in increased peak airway pressures. Warm or moist tubing is a perfect breeding area for bacteria. If this water is allowed to enter the humidifier, bacteria may be aerosolized into the lungs. Emptying the tubing also prevents introduction of water into the patient’s airways.
Assess airway pressure at frequent intervals.
Measure delivered tidal volume and analyze oxygen concentration every 4 hours or more frequently if indicated.
Monitor cardiovascular function. Assess for abnormalities. Monitor pulse rate and arterial blood pressure; intra-arterial pressure monitoring may be carried out.	Arterial catheterization for intra-arterial pressure monitoring also provides access for ABG samples.
Monitor for pulmonary infection Aspirate tracheal secretions and send to laboratory for culture and sensitivity testing. Monitor for systemic signs and symptoms of pulmonary infection (pulmonary physical examination findings, increased heart rate, increased temperature WBC count.	This technique allows for the earliest detection of infection or change in infecting organisms in the tracheobronchial tree.
Evaluate need for sedation or muscle relaxants.	Sedatives may be prescribed to decrease anxiety, or to relax the patient to prevent competing with the ventilator. At times, pharmacologically induced paralysis may be necessary to permit mechanical ventilation.
Monitor intake output precisely.	Negative fluid balance results in increase in body weight and interstitial pulmonary edema, which is frequent problem in patients requiring mechanical ventilation.
Monitor nutritional status.
Monitor GI function Test all stools and gastric drainage from occult blood.	Mechanically ventilated patients are at risk for development of stress ulcers. Stress may cause some patients to develop GI bleeding.
Provide for care and communication needs of patient with an artificial airway.
Provide psychological support. Assist with communication. Orient to environment and function of mechanical ventilator. Ensure that the patient has adequate rest and sleep.	Mechanical ventilation may result in sleep deprivation and loss of touch with surroundings and reality.
Suctioning Explain procedure to patient /family. Frequency of suctioning depends on patients. Tracheal suctioning is an aseptic procedures. Sterile catheter and one sterile glove to be used for each suctioning episode/session. Suction is applied while catheter is being withdrawn using rotatory movement and intermittent\ technique, not more than 10-15 seconds at a time. When secretions are tenacious, instill 1-3ml sterile normal saline into endotracheal/tracheostomy tube to liquefy and make removal easier.
Weaning process Assess patient for weaning criteria: Vital capacity -10 to 15ml/kg Maximum inspiratory pressure (MIP) at least 20cm H2O Tidal volume -7 to 9 mL/ KG Minute volume- 6L/min Rapid/shallow breathing index-below 100 breaths/minute/L. pAo2 greater than 60mm Hg with FiO2 less than 40%.	Careful assessment of multiple weaning indices helps to determine readiness for weaning. When the criteria have been met, the patient’s likelihood of successful weaning increases.
Monitor activity level, assess dietary intake, and monitor results of laboratory tests of nutritional status.
Ensure psychological preparation. Explain procedure and that weaning is not always successful on the initial attempt.	Explaining procedure to patient will decrease patient anxiety and promote cooperation. The patient should not be discouraged if weaning is unsuccessful on the first attempt.
Prepare appropriate equipment.	Increase lung compliance, decrease work of breathing.
Position the patient in sitting or semi fowler’s position.
Pick optimal time of day, preferably early morning.	The patient should be rested.
Perform bronchial hygiene necessary to ensure that the patient is in best condition (postural drainage, suctioning) before weaning attempt.
T-piece	T-piece
This system provides oxygen enrichment and humidify to a patient with an endotracheal or tracheostomy tube while allowing completely spontaneous respirations.
Discontinue mechanical ventilation and apply T-piece adapter.	Stay with the patient during weaning time to decrease patient anxiety and monitor for tolerance of procedure.
Monitor the patient for factors indicating need for reinstitution of mechanical ventilation. Blood pressure increase or decrease greater than 20mm Hg systolic or 10mm Hg diastolic. Heart rate increase of 20 beats/minute or greater than 110. Respiratory rate increase greater than 10 breaths/minute or rate greater than 30. Tidal volume less than 250- 300ml..	Indicates intolerance of weaning procedure
Increase time of ventilator with each weaning attempt as the patient’s condition indicates. Evaluate for toleration before moving to the next increment.	The patient will progress as e or she becomes mentally and physically able to perform adequate spontaneous ventilation.
Institute other techniques helpful in encouraging weaning. Mental stimulation Biofeedback Participation in care Provision of rewards	Provides motivation and positive feedback.
When patient tolerates 40-60 minutes of continuous weaning, weaning increments can increase rapidly.
When the patient can maintain spontaneous ventilation throughout day, begin night weaning.
CPAP weaning The principles and techniques for CPAP weaning are the same as for T-piece weaning.	This weaning techniques is preferred for patients prone to atelectasis when placed on a T-piece.
The patient breathes with CPAP at low level (2.5cm-5cm H2O), rather than with the T-piece, for periods that increase in length.	This determines the time interval between machine delivered breaths, during which the patient will breath on own.
IMV or SIMV meaning
Set ventilator to IMV or SIMV mode.
Set rate interval.
Evaluate for tolerance of procedure. In rapid weaning, changes may be made approximately every 20-30 minutes.
If the patient does not tolerate the procedure, the PaCo2 will rise and pH will fall. If PaCo2 and pH remain stable, then continue to decrease mandatory rate as patient tolerates.
Routine nursing care
Give daily bed bath and change bed linen, if soiled.
Provide attention to pressure sites every 2 hours by turning and repositioning the patient.
Oral hygiene every 4 hours and whenever needed.
Eye care every 4 hours and instill artificial tears and cover with gauze to prevent corneal abrasions in patients who are unconscious.
Check and record vital signs every hour.	May be done as frequently as every 20-30 minutes with ABG monitoring, pulse oximetry. Documentation of successful weaning.
Measure blood loss, urine, nasogastric, aspirate etc. every hour.
Change drainage bags, chest drainage bottles and tubing as required.
Maintain intake/output chart every shift.
Aseptic urinary catheter toilet every 8 hours.
Assess bowel action every third day.
Change tape anchoring ETT and Ryle tube as needed.
Change intravenous administration sets and dressing of puncture sites every day.
Change ventilator circuit tubing, connections, and adapters every day.
Psychological aspects of patient care Provide possible/suitable mean of communication-writing pad, hand signals, lip movement, using pictures, etc. Endeavor to allay patients and relative’s anxiety/fears, and clear doubts as necessary. Motivate patient and relative to participate in daily care. Promote good relationship with patient/family and encourage them to express fears, stress factors/feelings. Keep updating the relatives about the patient’s condition/progress.

NM1304a - TRACHEOSTOMY CARE

MEANING

Tracheostomy care includes changing a tracheostomy inner tube, cleaning, tracheostomy site and changing dressing around the site

PURPOSE

To maintain airway patency

To prevent infection at the tracheostomy site

To promote comfort

To facilitate heating and prevent skin excoriation around the tracheostomy site

ARTICLE

A tray containing

¨ Gloves

¨ Mask

¨ antiseptic solution

¨ Tracheostomy tie

¨ Straight scissors

¨ Kidney tray

¨ Normal saline 100ml

¨ Sterile suction catheter of appropriate size

¨ A tracheostomy tray containing

¨ Inner cannula

¨ Obturator

¨ Sterile bowl small

¨ Sterile gauze piece

¨ Artery Curved forceps

PROCEDURE

NURSING ACTION	RATIONALE
Check physician’s order	•Avoid errors
Identity patient by name hospital number	Ensures that right procedure is done on right patient
Assess the patient and explain the procedure	Gain cooperation and allay anxiety
Assemble all equipment near bedside	For easy access
Provide privacy and proper position ( semi fowlers position)	Helps the patient to cough and makes breathing easier
Put on the face mask & perform hand hygiene	Prevents cross contamination
Open the sterile package
Put on sterile gloves	Minimize transmission of surface flora
Suction tracheostomy tube	Removes secretions to prevent occluding outer cannula
Unlock the inner cannula and remove it by gently pulling it out
Place the inner cannula in the bowl small
Remove soiled dressing and dispose it	Prevents contamination
Clean the stoma under face plate using sterile gauze moistened with betadine (use each gauze only once. Moving from stoma site outward	Provide comfort
Dry the stoma with dry gauze
Clean the inner cannula · Wash under running water · Introduce a gauze piece from the top and remove it from the other end to clean inside · Send to CSSD
Stabilize the outer cannula and faceplate with one hand. Replace the inner cannula into outer cannula and secure it in place.
Apply sterile gauze dressing under faceplate	Absorbs debris, discharges collected around stoma
change the tracheostomy ties• · Cut a piece of tape that is twice the neck circumference plus 10cm. · Tie end of tape diagonally · Insert one end of tape through faceplate opening alongside of the plate · Pull through until both ends are even length · Slide both ends of tape under patient’s neck and insert one end through remaining opening on the other side of the faceplate · Assess the client status · Dispose waste as per JMMCRI policy · Remove gloves and perform hand hygiene	A secure tape prevents accidental expulsion of the tracheostomy tube Insert two finger to check the tie tightness Prevents contamination Reduce spread of microbes
Document (time, Provides patient status during and after the procedure) all relevant information in nurses record	Continuity in care and professional accountability

TRACHEOSTOMY DECANNUALTION

Decannualation is a planned intervention for the permanent removal of the tracheostomy tube once the underlying indication for the tracheostomy has been resolved or corrected.

EQUIPMENT

Tracheostomy kit

Set of tracheostomy tubes

Straight scissors

Tracheostomy ties or Velcro ties

Suction equipment

Gauze and an occlusive dressing

Cotton wool applicators

Small towel

Oxygen administration devices

Crash cart

Monitoring equipment

PREPARATION

NURSING ACTION	RATIONALE
Identify the patient by hospital number.
check physician order
Assemble the articles near patient side.
Prepare necessary personal protective including goggles
Obtain baseline data including; heart rate, respiratory rate, SpO2 (hemoglobin-oxygen saturation) and work breathing.
Ensure the patient takes fasting for a few hours.
Clearly explain the procedure to the patient.
Position the patient. Sitting position is preferred.
Perform hand hygiene and apply non-sterile gloves.
Remove fenestrated dressing from around the stoma.
Clean the stoma site and suction the tracheostomy tube immediately prior to decannulation.
Cut/undo tracheostomy tube ties.
Remove tracheostomy tube.
Observe closely for any signs of respiratory distress including. Tachypnea Stridor Retraction Tachycardia Color Decreased perfusion Oxygen desaturation and low oximetry reading Restless or anxiety Decreased cough effectiveness, swallow and voice quality Activity levels
If no evidence of respiratory distress an occlusive dressing is applied to stoma site to ensure an airtight seal and reassess patient foe any signs of respiratory distress.
Monitor patient vital signs 15 minutes for the first hour Half hour for the next hour Hourly for 24 hours Continuous pulse oximetry during all periods of sleep post decannulation for 24 hours. Observe carefully for any signs of airway obstruction
Offer light diet 2 hours after decannulation.
Cover the stoma site by a small gauze and then by an occlusive dressing
Assess the occlusive tracheal stoma dressing for air leaks
Change the stoma dressing daily until it has closed or no secretions seeping out.
Observe the skin reactions to dressing.
Encourage coughing to clear secretions from upper airway. If not gentle oropharyngeal secretions can be performed.
Provide comfortable position to the patient and observe for any complication.
Discard the article as per JMMCRI policy.
Doff gloves and perform hand hygiene.
Document all relevant data in the medical record.

NM1305a - ORAL SUCTIONING

ARTICLES

• Sterile suction catheters (12-16 Fr for adult and no. 8-10 Fr for child.)

• Yankeur suction catheter

• Suction canister

• Normal saline

• AMBU bag

• Stethoscope

• Personal protective equipment

• Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient by hospital number and name.	Right procedure is done on right patient.
Arrange the article s at the bedside.	It will ease the procedure.
Ensure suction unit, canister, tubing are setup ready for use.
Perform hand hygiene.
Wear personal protective equipment.
Turn on suction machine.
Insert catheter into the mouth and apply suction to lower gums around the teeth.
Do not apply suction further back into the mouth/throat than the back teeth.	To avoid mucosal injury.
Suction not more than 10 seconds.	To reduce the risk of hypoxemia.
There should be 10-15 seconds gap between two suctions.	It helps to re-oxygenate the patient.
After suctioning insert the catheter tip in normal saline.
Empty the canister.
Clean, disinfect and replace articles as per JMMCRI policy.
Discard the waste as per JMMCRI policy.
Remove gloves and perform hand hygiene.
Document all relevant information.

ROCEDURE

NM1305b - ENDOTRACHEAL SUCTIONING

DEFINITION

The process of applying a negative pressure to the distal endotracheal tube or trachea by introducing a suction catheter to clear excess, or abnormal secretions.

TYPES

Closed suction system

An in-line suction catheter is connected to the ventilation circuit and endotracheal tube suction procedure can be performed without disconnecting the patient from the ventilation circuit.

Open suction system

Open suction describes the disconnection of the patient from a ventilator or wall oxygen system, and passing the single –use suction catheter into the patient airway.

PURPOSE

· To maintain a patent airway and prevent airway construction

· To promote respiratory function

· To prevent pneumonia

· To obtain specimen for analysis and culture

ARTICLE

A tray containing:

· Sterile suction catheters 12-16 Fr for adult and no. 8-10 Fr for child. /calculate the size by using formula

Size of ET tubex3

· Normal saline

· Syringe 10mL

· Stethoscope

· Personal protective equipment (mask, gloves)

· Kidney tray

PROCEDURE OF OPEN SUCTION SYSTEM

NURSING ACTION	RATIONALE
Identify the patient and assess rate of respiration, breath sounds, oxygen saturation ,and heart rate	To determine the need of suctioning
Explain the procedure	To reduce fear & gain cooperation
Assemble equipment, check functioning of suction apparatus	It conserves time & energy. Correct pressure minimizes mucosal damage in trachea and atelectasis.
Provide proper position ( preferably semi fowlers ) and privacy
Pre oxygenate the patient via the ventilator, or wall mounted oxygen, for at least 30 seconds. Check oxygen saturation prior to beginning suctioning	To optimize the patient’s oxygenation and minimizes hypoxemia and cardiac dysrhythmias.
Disable the ventilator and monitoring alarms as needed.
Connect AMBU bag to oxygen source and endotracheal tube.	Hyper oxygenate the patient
Wear mask and perform hand hygiene	Prevent spread of infection.
Don sterile gloves. Designate non-dominate hand as clean and dominant hand as sterile.	Sterility of the suction catheter is maintained.
Pick up the connecting tubing with non-dominant hand and connect the sterile suction catheter to connecting tube with dominant hand.
Turn on suction source with clean hand.
Utilizing a non-touch technique gently introduce the suction catheter tip into the tracheostomy tube to the premeasured depth.
Do not apply suction whilst introducing the catheter, or push against resistance at any time.	Suctioning while introducing the catheter causes mucosal irritation, damage & hypoxia.
Occlude suction port with gloved thumb and gently rotate the catheter while with drawing. Each suction should not be any longer than 5- 10 seconds.	Prolonged suctioning can cause hypoxia and trauma.
Assess the patient respiratory rate, skin color and/or oximetry reading.	Tracheal suction may cause vagal stimulation leading to bradycardia, hypoxia and may stimulate bronchospasm.
Flush & lubricate the catheter by dipping it into the container of normal saline	Remove secretions from the catheter.
Oxygenate the patient simultaneously	Prevent saturation fall.
When the airway becomes clear, return the patient to ventilator if patient is on ventilator
Repeat suctioning as needed and according to patients tolerance
Suction oral secretions from the oropharynx	Remove accumulated oral secretions
Flush the suction tube with normal saline	Removes secretion from suction tube
Turn off suction and disconnect catheter from suction connection tubing
Discard the gloves & suction catheter as per JMMCRI policy	Reduces spread of microorganism
Replace the article and wash hands	Reduces spread of microorganism
Position patient comfortably, reassess the patient’s respiratory status	Ensure respiratory passages are cleared of secretions
Record the procedure and patients response in nurse’s record ( time, color, consistency)	Provide continuity in care

NOTES

· Discard the suction catheter after each suction

· Discard suction connection tube after 24hrs

· Fill the suction container with 0.1% sodium hypochlorite solution prior to procedure

· Keep the suction apparatus neat and dry after each and every use-take care to clean the hub and up neatly

Closed suction system

Explain the procedure to the patient.	Provide reassurance and helps to reduce anxiety.
Perform hand hygiene. Don personal protective equipment.	To minimize the risk of cross infection to patient or health care professional.
Check correct function of suction unit. Lift the thumb valve cap to unlock it, then depress and hold the valve and simultaneously adjust the suction pressure. Ensure pressure between 100-150mmHg.	Correct pressure minimizes mucosal damage in trachea and atelectasis.
Pre oxygenate the patient via the ventilator, or wall mounted oxygen, for at least 30 seconds. Check O2 saturations prior to beginning suctioning.	To optimize the patient’s oxygenation and minimize hypoxemia and cardiac dysrhythmias.
Insert the catheter gently on inspiration, do not apply suction during inspiration.	Suctioning while introducing the catheter causes mucosal irritation, damage and hypoxia.
Continue to pass the catheter until the patient coughs, or when the correct depth is reached. If resistance is felt with draw the catheter 1-2cm before suctioning, to ensure tip is not touching the carina.	Minimizes mucosal damage to the carina.
Apply suction continuously during catheter removal, withdraw catheter fully until the black marking on the catheter is visible.	Intermittent suctioning is less effective.
The period of suction should not exceed 10 seconds.	To minimize risk of hypoxemia
Monitor the patient’s condition throughout and following the treatment, to detect complications promptly.	Tracheal suction can cause vagal stimulation, leading to bradycardia, hypoxia, or bronchospasm.
Repeat procedure as indicated but allow the patient time to recover between suctions.it is recommended that no more than 3 episodes of suctioning are carried out in succession.	To decrease risk of hypoxia, limit side effects and avoid patient tiring.
Clean catheter tip with saline after each of the catheter and remove immediately do not leave attached.	Cleaning should take place after every suction pass to prevent contamination and catheter occlusion.
When suctioning has finished, rotate thumb control to locked position.	For safe practice.
If oxygen was increased prior to procedure, return to previous setting.
Discard waste as per JMMCRI policy.
Clean disinfect and replace the article as per JMMCRI policy.	To reduce the risk of bacterial growth in the water or tubing.
Perform hand hygiene.
Document all relevant information in the nurses record.

NM1305c - TRACHEOSTOMY SUCTIONING

Suctioning of the tracheostomy tube is necessary to remove mucus, maintain patient airway and avoid tracheostomy tube blockage.

INDICATION

Audible or visual signs of secretions in the tube

Signs of respiratory distress

Suspicion of blocked or partially blocked tube

Inability by the person to clear the tube by coughing out the secretions.

Vomiting

Desaturation on pulse oximetry

Changes in the ventilation pressure

ARTICLE

Suction apparatus

Suction canister

Tubing

Suction catheter

Normal saline

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient by hospital no and name
Select appropriate size suction catheter. The diameter of the catheter should be no more than half the internal diameter of the tracheal tube.
Tape measure with depth required for tracheostomy tube suctioning with a spare tracheostomy tube and suction catheter.
Correct suction pressure for use on a tracheostomy tube is less than 200mmHg.	To ensure that machine is in working condition. Too great a suction pressure can cause trauma, hypoxaemia and atelectasis.
Perform hand hygiene and apply clean gloves.	Reduce the risk of cross infection.
Consider pre-oxygenation if receiving oxygen or ventilated.	To prevent hypoxaemia.
Remove HME, mask or circuit from the tracheostomy tube.	To allow access for sterile suction catheter tip.
Peel open suction catheter end and attach to suction tubing sterilely	To reduce the risk of transmission infection from the hands to the suction tubing.
Utilizing a non-touch technique gently introduce the suction catheter tip into the tracheostomy tube to the premeasured depth.
Do not apply suction whilst introducing the catheter, or push against resistance at any time.	Suctioning while introducing the catheter causes mucosal irritation, damage & hypoxia.
Occlude suction port with gloved thumb and gently rotate the catheter while with drawing. Each suction should not be any longer than 5- 10 seconds.	Prolonged suctioning can cause hypoxia and trauma.
Assess the patient respiratory rate, skin color and/or oximetry reading.	Tracheal suction may cause vagal stimulation leading to bradycardia, hypoxia and may stimulate bronchospasm.
Repeat the suction as indicated by the patient’s individual condition.
Connect the HME, mask or circuit to the tracheostomy tube.	To limit hypoxia.
Notify the color of the secretion	Normally it is white or clear and easy to remove. When infection occurs the color and consistency will change.
Rinse the suction catheter with sterile water decanted into the container.
Discard the waste as per the JMMCRI policy.

NOTES

Single use suction catheter is recommended.

Clean the suction canister as per JMMCRI policy.

Routine use 0.9% sodium chloride into the tracheostomy tube is not recommended.it can be used if thick secretions are present or to stimulate cough.

NM1401a - RESTRAINTS

DEFINITION

Restraints are defined as the intentional restriction of a person’s voluntary movement or behavior. Mechanical devices used to immobilize and protect a person from injury to facilitate examination, to aid in performing diagnostic tests and therapeutic procedures. Restraints are a safety intervention and enable to facilitate therapeutic procedure.

METHODS

Physical restraints

Chemical restraints

Environmental restraints

Physical restraints

It encompass hand mits, soft cloth limb restraints, leather limb restraints, enclosed beds, belts and vests.

Types

Mummy restraint

Elbow restraint

Extremity restraint

Abdominal restraint

Jacket restraint

Mitten or finger restraint

Chemical restraints

These are any form of psychoactive medication used not to treat illness, but to intentionally inhibit a particular behavior or movement. E.g. sedatives, hypnotics, neuroleptics.

Environmental restraints

It control a client’s mobility. E.g. secure unit/garden, seclusion.

INDICATION

• Displaying behavior that is putting themselves at risk of harm.

• Displaying behavior that is putting others at risk of harm

• Requiring treatment by a legal order (mental health act, 2007)

• Requiring urgent lifesaving treatment.

PURPOSE

• Provides safety and comfort

• Facilitate examination

• Carry out diagnostic and therapeutic procedures

• Keep a person in desired position

EQUIPMENT

• Draw sheet (mummy restraint)

• Cotton pads

• Knitted bandages

• Limb restraint strap

HOW TO MANAGE A PATIENT IN RESTRAINT

• Provide diversional activity.

• Decrease stimuli and nose.

• Provide change of position, ambulation.

• Have patient to wear supportive medical devices like (glasses, hearing aids, etc.).

• Offer fluids and nourishment frequently, keep water within reach.

• Offer bedpan or bathroom every 2 hours.

• Increase observation (ask family to sit with patient, alert other staff to be observant).

GENERAL INSTRUCTIONS

· Assess whether restraint is needed

· Remove restraint periodically and examine for complication

· Observe for complication such as injury to brachial plexus, pressure sore, impaired circulation, and compression of nerves

· Patient or bystander must be informed about the type of restraint and why he/she is restrained. Consent must be obtained from the patient or the bystander.

· Should not interfere with treatment.

· Obtain physician order and it is valid for one particular admission.

· Restraint order has to be renewed in every 24 hours.

· Monitor the restraints as per JMMCRI policy.

PROCEDURE

NURSING ACTION	RATIONALE
Explain to person /bystander reason for restraining.	Explanation reduces anxiety.
Provide adequate padding before restraining.	Excessive pressure due to restraints can lead to decreased blood supply to the restraint body part.
Apply restraint firmly and gently, but not tightly.	The restraint should not be too loose or too tight and not serve the purpose.
Keep joins in anatomical position.	Maintaining in anatomical position prevents strain on the joints.
Restraint only one joint at a time.	Minimizes discomfort and promotes movement and activity and minimizes fear of decreased sense of self control.
MUMMY RESTRAINT( for newborn restraint) · Fold draw sheet into a square and fold one corner. · Place infant supine on the sheet with the top of the sheet at his/her shoulder line and bottom of the sheet extending approximately 10-12 inches beyond his/her feet. · Place the infant’s arm at side in anatomical position. · Fold one side of the sheet over body and under opposite side, tucking excess linen securely under the infant. · Place the other arm in anatomical position. · Fold appropriate side of the sheet over body and under back. · Take lower fold over the infant and tuck under chin	· Correct method of mummy restraint will serve the purpose of providing comfort · Extremities will be restrained for appropriate procedure · Draw sheet should be correctly prepared to avoid infant moving the hands and legs during the procedure · Ensures adequate coverage of the infant. · Anatomical position prevents stiffness and strain on muscles at the joints of the extremities. · Prevents loosening up of the restraint. · Maintaining anatomical position prevents fractures and tissue injuries · Prevents infant from un-restraining the mummy restraint
ELBOW RESTRAINT · Wrap elbow restraint should be of adequate size and placed around elbow of both the hands and secured with ties. · Ensure that elbow joints are covered completely.	· Elbow restraint ties will enable to prevent flexing of elbows, which is required to prevent hands reaching the mouth. · Elbows restraint should be big enough to ensure adequate immobilization.
JACKET RESTRAINT · Fit jacket to patient with opening and tapes facing back. · Securing tapes to chair, wheel chair or cot.	· Securing with jacket restraint will promote immobilization of the trunk. · Ensures immobilization of the trunk to prevent moving out of the bed of wheel chair.
ABDOMINAL RESTRAINT · Place patient in supine position. · Place abdominal restraint over the abdomen of the patient · Secure tape at the side of cots to keep the child in supine position.	· Prevents immobilization of the trunk to prevent moving out of the bed or wheel chair.
MITTEN RESTRAINT · Place mitten (a glove shaped linen bag) on both hands and secure over wrists with ties. · Using a bandage appropriate to the infant’s hand, make circular folds below the wrist and make turns over the padded flexed fingered fisted hand, covering 2/3 portion of previous layers	· Promotes restraining of fingers and preventing fingers disturbing nasal tubing. · Appropriate size of the bandage for the size of the infant’s hand will ensure adequate restraint.
EXTREMITY RESTRAINT · Wrap the restraint around the limb facing the soft part facing the skin. · Use the Velcro straps to secure the device. · It should not be too tight so that two fingers can be slipped between the restraint and patient’s wrist or ankle. · Use quick release tie to secure the restraint to the stationary part of the bed frame. · It must be out of the patient’s reach.	· Soft wrist and ankle restraints may be used to prevent a patient from interfering with cares, such as pulling at an IV or other tubes or removing a dressing.

CHEMICAL RESTRAINTS

A chemical restraint is a form of medical restraint in which a drug is used to restrict the freedom, movement of a patient or in some cases to sedate a patient.

It includes psychopharmacologic agent, psychotropic drug or therapeutic restraints.

PURPOSE

Chemical restraints use to calm or sedate a person temporarily.

It uses as an alternative when other measures of restraints are failed.

DRUGS

Benzodiazepine

Antipsychotics

Dissociative anesthetics

ENVIRONMENTAL RESTRAINT

An environmental restraints is a restrictive practice that restricts a person’s free access to all parts of their environment including items and activities.

It may include use of locks, padlocks or enforceable limits or boundaries beyond normal community practices to limit a person’s access to items, activities for the purpose of managing a risk or behavior of concern.

NM1501a - ARTERIAL LINE INSERTION

DEFINITION

Arterial catheterization is a procedure to facilitate hemodynamic monitoring and arterial blood sampling.

PURPOSE

· To accurately assess acid base status.

· To assess degree of oxygenation of blood and adequacy of alveolar ventilation.

· To monitor arterial blood pressure.

· To monitor cardiac output.

ARTICLES

§ A sterile tray containing;

¨ Bowl small-2

¨ Artery Curved forceps

¨ Sponge holding forceps

§ Arterial catheter of appropriate size.

§ Preheparinized syringe/arterial blood collection syringe.

§ Antiseptic solution ( spirit/chlorhexidine and povidone-iodine)

§ Sterile gauze

§ PPE- (Sterile gown, Sterile gloves, mask, face shield)

§ Transducer set

¨ Pressure bag

¨ Pressure Monitoring line(200cm)

¨ Pressure monitoring Transducer cable

¨ Normal saline

§ Local anesthetic 2%

§ Guide wire(seldinger technique)

§ USG with linear probe

§ Kidney tray

§ Transparent Occlusive dressing

§ Label

PROCEDURE

NURSING ACTION	RATIONALE
Check physician’s order.	Right procedure is done for right patient.
Identify the patient and the site.
Explain the procedure to the patient and family	Helps in obtaining cooperation
Ensure privacy
Record patient’s inspired oxygen concentration (FiO2) set on ventilator.(if needed)	Degree of hypoxemia cannot be assessed without knowing the inspired oxygen concentration
Assess the saturation with spo2 probe
Check patient’s temperature	Hypothermia or hyperthermia influences oxygen release from hemoglobin
Perform Allen’s test Perform Allen’s test with spo2 probe. ¨ Applying pressure on radial artery and check the saturation at little finger/ring finger ¨ Applying pressure on ulnar artery and check the saturation at thumb finger/ index finger. If radial artery is selected for puncture, perform the Allen’s test a. Obliterate radial and ulnar pulses simultaneously by pressing on both blood vessels at the wrist b. Ask patient to clench and unclench fist until blanching of skin occurs c. Release pressure on ulnar artery watch for return of skin color within 15 seconds. d. Obliterate the radial and ulnar pulses simultaneously e. Elevate patient’s hand above heart and squeeze or compress hand until blanching occurs f. Lower patient ‘s hand while still compressing the ulnar artery and watch for return of skin color	Ensures effective collateral circulation The Allen’s test is a simple method for assessing collateral circulation in the hand Forces blood from hand Identifies that Radial artery alone is capable of supplying blood to the hand while ulnar artery is occluded
Positioning the patient For radial artery puncture, the wrist needs to be hyper extended by keeping a soft roll under the wrist. For femoral artery puncture, place patient in supine position with leg straight
Arrange the articles near bedside.
Wash hands.	Prevents contamination
Don on sterile gloves
Prepare the site. Alcohol/chlorhexidine-povidone-iodine-alcohol/chlorhexidine
Drape the patient
Heparinize the 2mL syringe a. Withdraw heparin into syringe to wet the plunger and fill dead space. b. Hold syringe in an upright position and expel excess heparin and air bubbles in the needle	This action coats the interior of the syringe with heparin to prevent clotting Air remaining in the syringe may be affect measurement of paO2.Heparin in the syringe may affect measurement of pH.
Ensure that pressure monitoring line with transducer is primed with heparinised saline and connected to bedside monitor
Perform arterial puncture on area where good pulse is palpable.
Assist to administer local anesthetic agent.
Assist physician to insert arterial catheter.
Collect sample if ordered.
Assist in suturing the site if needed.
Connect pressure IV tubing zero the line to atmospheric and check for pressure arterial waveform on bedside monitor.
Cleanse allow the site to dry
Secure arterial line with adhesive tape with the date and time for insertion. Write arterial line on the label as high alert.
Make the patient comfortable
Replace the article
Watch for complications such as hematoma, hemorrhage, , arterial vasospasm, peripheral ischemia and infection,
Check the patency at regular intervals.

CARE OF ARTERIAL LINE

· Monitor the waveforms to identify overdamping or underdamping.

· Calibrate the arterial line. It avoids the pressure from the atmospheric pressure.

· Zeroing must be done often once per shift or when values are questionable.

· Ensure the transducer pressure tubing and flushing solution are assembled correctly and free of air bubbles. Place the transducer at the level of right atrium (4^th intercostal space at the mid-axillary line (phlebostatic axis).

· Turn stopcock off to the patient, remove cap. Press zero to set atmospheric pressure to a zero reference point. Replace the cap and turn the stopcock back to neutral.

· Whenever the patient position is altered, the transducer height should be altered to keep it at the level of atrium

· Compare the arterial pressure with non-invasive blood pressure. Discrepancies of more than 20mmHg or more are considered to be inaccurate.

· Check for pain in the extremity.

· Check for the collateral pulse and capillary refill.

· Check the hand for pallor and cyanosis.

· Assess the sensation (no numbness or tingling)

· Assess the extremities are moving.

· While collecting blood sample first draw 10ml of blood and then obtain the sample for test. Reinfuse the first 10ml back.

· Remove the catheter site dressing if the dressing become damp, loosened or visibly soiled.

REMOVAL OF ARTERIAL LINE

WHEN TO REMOVE

Replace arterial catheters only when there is a clinical indication.

Remove catheter as soon as it is no longer required.

EQUIPMENT

PROCEDURE

NURSING ACTION	RATIONALE
Explain the procedure.
Assemble the articles.
Check medication that affects coagulation. Risk for bleeding.	Significant coagulopathy contribute to the risk of bleeding.
Position the patient.
Remove dressing and perform hand hygiene.
Cleanse the site with antiseptic solution.
Position gauze over insertion site and gently withdraw the catheter slightly to ensure that catheter will withdraw easily.
Pull the catheter in a slow but steady withdrawal motion applying immediate and directly pressure slightly above the insertion site upon removal.
Inspect catheter for intactness.	To identify any catheter breakage.
Ensure hemostasis, hold direct pressure firmly and apply for 5 minutes.	Adequate pressure is needed to stop bleeding.
When bleeding stops completely apply a transparent dressing.	The occlusive dressing helps visualization of site while preventing pathogens preventing entering tract.

POST REMOVAL ASSESSMENT

· Minimize the limb movement for at least one hour. Ensure limb site is visible in order to promptly detect bleeding.

· Monitor for hematoma or bleeding.

· Assess distal extremity and observe for decreased circulation.

· Document the follow up in the nurse’s record.

NM1502a - INSERTION OF CENTRAL VENOUS CATHETER

DEFINITION

Insertion of a central venous catheter into a large central vein and advanced until the terminal lumen resides within the inferior vena cava, superior vena cava or right atrium

SITES

a. Internal jugular vein

b. Subclavian vein

c. Femoral site

PURPOSE

To obtain measurements of central venous pressure

To administer drug preparations which is harmful to smaller lumen peripheral veins

(Electrolytes, inotropes)

To administer large amount of fluids in short time ( for hypovolemia patient)

When unable to access peripheral line.

To have a long term IV access

To administer parenteral nutrition

To assess pulmonary artery pressure

ARTICLES

v Sterile CVP tray containing towel, hole towel, sponge holder, needle holder, non-toothed forceps, BP handle (No.3/7), 2 bowl small, gauze.

v PPE (Sterile gown, mask, sterile gloves)

v Sterile prep solution( povidone iodine, alcohol/ chlorhexidine)

v 10 mL & 5mL syringe

v Local anesthetic solution

v Heparin

v Normal saline

v Central line pack-includes multi-lumen indwelling catheter, spring-wire guide, introducer needle and syringe (luer-slip), tissue dilator, dust cap ( non-vented), second site adjustable hub and catheter clamp, spring wire introduction syringe, pressure transduction probe.

v Suture material

v Sterile Transparent dressing

v Protective end caps/3 way stop cock

v Kidney tray / foot-operated waste liners

v USG machine with linear bag

v USG Gel

v Camera cover

v Shoulder bag

PROCEDURE

NURSING ACTION	RATIONALE
Explain to patient how the procedure will be carried out and the sensation he would feel during insertion. Ensure procedure consent has taken, witnessed by staff nurse.	Reduces patient anxiety
Check physician’s written order for type of catheter and number of lumens.	Ensures accurate type and style of catheter is inserted
Assemble articles at the bedside and make provisions for privacy. Provide a well-lighted area.	Provides for smooth performance of the procedure
Assess the site.	For easy initiation of procedure
Flush the lumen catheter with heparinized saline and close the lumens with 3-way stopcock or clamp.
Wash hands and don personal protective equipment.	Reduces spread of micro-organisms
Position patient to lie flat with a slight head—down tilt. Turn head to left and slightly up. Apply shoulder bag	Helps easy identification of land marks for cannulation of central vein
Clean the neck and upper chest with alcohol/chlorhexidine then povidone-iodine followed by alcohol/chlorhexidine and drape with sterile hole towel	Minimizes risk of contamination, helps create a sterile field to work
Assist the physician with administration of local anesthesia and mark the area.	Minimizes pain sensation for patient
Attach a 10 mL syringe to the needle. Physician inserts the needle into the selected central vein. The needle is advanced while aspirating continually.	Easy aspiration of dark colored venous blood indicates that the needle is in the correct location
Once the physician is reasonably certain that the needle is within the lumen of the vein, the syringe is removed and the guide wire is inserted in the needle
Once the wire is positioned, physician with a No.11 scalpel blade physician makes a small nick in the skin over the guide wire.	Small nick over the guide wire permits insertion of dilated device
Physician passes the dilating device down the wire and inserts it fully into the vessel lumen. Nurse assists by holding the patients head steady.
Physician removes the dilating device and inserts the central venous catheter by passing it down the guide wire and into the vessel.
Physician removes the guide-wire and confirms the position of catheter by aspirating blood from the catheter. Send the blood for ABG to confirm the site.
Provide physician with sterile heparinized saline flush solution to flush the catheter to keep the lumen patent.
Assist physician to secure the catheter in place with sutures.	Sutures ensure positioning of the catheter
Provide physician with three way taps to attach to each lumen. Ensure every port is flushed.	Prevents clogging of catheter lumens
Assist physician in applying sterile transparent dressing over the catheter insertion site	Sterile dressing minimizes entry site infections
Reposition the patient. Discard waste, wash and replace reusable articles. Perform
Arrange for a portable chest x-ray to be obtained if prescribed by physician.	Chest X-ray helps to ensure proper central venous catheter placement
Record in the nurse’s notes, date and time of catheter insertion type of catheter inserted, the insertion site, chest x-ray result, CVP monitoring and how the client tolerated the procedure. Also maintain bundle checklist for CLABSI	Helps to communicate information to health professionals

COMPLICATION

Hemorrhage

Hematoma

Pneumothorax

Misplacement or malposition of catheter

CARE OF CENTRAL VENOUS CATHETER

DEFINITION

Regularly monitoring the central venous catheter to avoid further complication.

ARTICLES

· Sterile dressing tray containing Artery Curved forceps/sponge holders, 2 Bowl smalls, Gauze.

· Cleaning solution(Alcohol/chlorhexidine, povidone-iodine)

· Transparent adhesive dressing

· Sterile pad

· Adhesive tape

· Sterile gloves

· Syringe

· Heparinized saline

· Mackintosh/ under pad

· Kidney tray

HUB DISINFECTION

NURSING ACTION	RATIONALE
Explain the procedure to the patient	Reduces anxiety and enhances cooperation
Perform hand hygiene and don the gloves	Reduces transmission of micro-organism
Prepare a syringe with 10mL heparinized saline flush solution.	Preparing articles in advance allows for smooth performance of procedure.
Clamp the catheter	Prevents air entry into the catheter. Always clamp the catheter before removing the cap. Never leave an uncapped catheter unattended.
Disinfect the hub with 70% alcohol a. Prior to cap removal, disinfect the cap and the hub that is visible and discard the antiseptic swab. b. Remove the cap and disinfect the hub with a new antiseptic swab. c. Clean the sides(thread)and end of the hub thoroughly with friction making sure to remove any residue.( e.g., blood) d. Using the same antiseptic swab, apply antiseptic with pressure to the catheter moving from the hub at least several centimeters towards the body. e. Hold the limb while allowing the antiseptic to dry. f. Use a separate antiseptic swab for each hub or catheter limb g. Always handle the catheter hub aseptically. Once disinfected do not allow the catheter hubs to touch non-sterile surfaces

FLUSHING

Check catheter for patency a. Attach syringe with heparinized saline b. Release clamp/open 3-way stop cock c. Aspirate old heparin solution from the catheter and observe blood return d. Flush quickly with normal saline and re-clamp. e. Remove empty syringe.	opens catheter lumen and ensures patency of the catheter
Flush with heparin solution quickly. a. Attach syringe filled with 5mL heparin solution to catheter. b. Release clamp/open 3-way stopcock c. Flush quickly and re-clamp
Place cap on end of catheter, tape all tubing connections, and attach tubing to clients clothing	Maintain sterile seal.
Cover with the entire catheter leaving the tip outside with sterile pad	To reduce the risk of infection.
Dispose of soiled articles and supplies, clean and replace reusable articles	Reduces transmission of microorganism
Wash hands	Reduces transmission of microorganism
Document in nurse’s record the procedure with time and observations made	Communicates with other health professionals

NOTES

· Flush the line 6^th hourly

· Do not flush the line if inotropes are on flow

REMOVAL OF CENTRAL VENOUS CATHETER

DEFINITION

This procedure will take place when a central line leads to be disconnected. This may be because the line is no longer needed or is no longer functioning as it should be.

PURPOSE

When central venous catheter is not necessary.

To avoid complication related to infection at catheter site.

To rectify inadequate blood flow or any block in catheter

ARTICLE

§ Sterile tray

§ Cleaning solution( alcohol/chlorhexidine, povidone-iodine)

§ Adhesive dressing

§ Kidney tray

§ Mackintosh

§ Suture cutting scissor/surgical blade with BP handle

§ Sterile gauze pack

§ Pressure bandage

§ Sterile culture bottle

PROCEDURE

NURSING ACTION	RATIONALE
Explain the procedure
Check INR/PTT and platelets, medications that affect coagulation.	Significant coagulopathy, medications and catheter site contribute the risk of bleeding
Prepare the patient. Provide well lighted area.
Assemble the articles.
Position the client appropriately. Trendelenburg position	Position must be below the heart level
Remove dressing and discard. perform hand hygiene
Remove sutures
Apply dry gauze over insertion site and gently attempt to withdraw the catheter	2.5cm to assess for easy removal.
Ask the patient to hold the breath during removal or remove at the end of inspiration if mechanically ventilated
Pull the catheter in a slow but steady withdrawal motion , applying immediate direct pressure slightly above the insertion site upon removal
Cut the catheter tip for culture (if asked) and transfer to the culture bottle sterilely)
Apply continuous and direct pressure for a minimum of 5 minutes before assessing for bleeding
Inspect catheter for intactness. Notify physician immediately if catheter is damaged

FEMORAL LINE REMOVAL

Apply direct pressure above the puncture site (at 90⁰) to occlude blood flow.	To reduce the risk of air embolism
Ensure homeostasis	To reduce the risk of hematoma

Post-removal assessment

Keep patient flat with minimal activity for at least one hour following subclavian /jugular line and 2 hours following femoral line removal.

Monitor for bleeding, oozing from site.

Apply pressure to the site in case of hematoma.

Cold compress may be applied in case of hematoma.

Check femoral pulse and instruct patient to avoid unnecessary movement.

NM1503a - ASSISTING EXTERNAL JUGULAR CANNULATION

INTRODUCTION

The external jugular vein collects most of the blood from the outside of the skull and deep part of the face. It lies outside the sternocleidomastoid muscle and passes down the neck to join the subclavian vein.

The external jugular vein may be used for central venous access. It is a superficial vein, allowing easy control of hematoma and, differently from the internal jugular vein (IJV) access, with no risk for airway obstruction in patients with significant coagulopathies.

INDICATION

o Repeated blood sampling

o Administration of fluid

o Administration of medications

o Administration of chemotherapeutic agents

o Nutritional support

o Administration of blood and blood products

o Administration of radiologic contrast agents

CONTRAINDICATION

o Vesicant solutions can cause blistering and tissue necrosis as it is extremely acidic or basic.(e.g. potassium chloride, calcium gluconate, dopamine, chemotherapeutic drugs)

EQUIPMENT

o Cannula of appropriate size (16G,18G)

o Non-sterile gloves

o Antiseptic solution

o Dry Gauze

o Local anesthetic solution

o Saline or heparin lock

o Transparent dressing

o Adhesive tape.

PROCEDURE

NURSING ACTION	RATIONALE
Explain to patient how the procedure will be carried out and the sensation he would feel during insertion. Obtain verbal consent.	Reduces patient’s anxiety and enhances co-operation.
Check physician’s written order.
Assemble articles at the bedside and make provisions for privacy.	Provides for smooth performance of the procedure.
Perform hand hygiene.	Reduces spread of microorganism.
Make sure that there is adequate light.	Easy to visualize the procedure.
Position patient to lie flat in trendelenburg position, slightly tilting head to the opposite side.	Helps easy identification of land marks for cannulation.
Assess the external jugular vein.	External jugular vein tends to collapse during the patient’s inspiration.
Apply mild pressure over the vein just above the patient clavicle.	It helps to engorge the vein.
Select proximal site for intravenous catheter insertion far from the clavicle.	It helps to avoid accidental lung injury.
If difficulty is encountered in finding an appropriate vein, Inspection of the opposite side. Gravity Gently tapping or stroking the site Applying heat
Don gloves.
Clean the neck and upper chest with spirit, followed by betadine, spirit and drape with sterile towel.	Minimizes risk of contamination, helps create a sterile field to work.
Allow it to air dry for up to one minute.	It ensures the disinfection of the site and to prevent stinging as the stylet pierces the skin.
Stabilize the vein using non-dominant hand (thumb), applying traction to the skin distal to the chosen site of insertion.	It prevents the vein from rolling away from the stylet. Maintain the stabilization throughout the procedure.
Hold the cannula in the dominant hand, with the bevel up.	It ensures the penetration of the sharpest part of the stylet to the skin.
Inset the stylet at an angle 10-25⁰.	External jugular vein is usually superficial.
When the blood is visible in the chamber of cannula reduce the angle of the cannula.	It prevent puncturing of posterior wall of the vein.
Advance the cannula gently and smoothly to an additional 2-3mm into the vein.
Hold the stylet grip portion of the venous access device in place between the dominant hand and the middle finger.
Use the dominant index finger to slide the hub of the cannula over the stylet and into the vein.
Withdraw the stylet and attach the pre-flushed saline or heparin lock to the hub of the cannula.
Withdraw a small amount of blood to confirm that the cannula is inside the vein and immediately flush the cannula.
Secure the venous access device to the skin using the transparent dressing and tape.
Place a label indicating date, time, and other required information over the transparent dressing.
Reposition the patient. Discard waste, wash and replace reusable articles.
Record in the nurse’s notes, date and time of cannula insertion, the insertion site, and how the client tolerated the procedure.	Helps to communicate information to health professionals.
Watch for complication.

Note

v If no blood is observed in the flashback chamber, the cannula should be withdrawn to just beneath the skin level. Flashback may stop if the device is punctured the posterior wall of the vein or if the patient is extremely hypotensive.

v If swelling develops, withdraw the cannula apply direct pressure for 5 minutes, as a hematoma developed.

COMPLICATION

o Pain

o Collapse of the vein

o Venospasm

o Hematoma

o Thrombophlebitis

CARE OF EXTERNAL JUGULAR CANNULA

ARTICLES

o Non-sterile gloves

o Antiseptic solution

o Saline or heparin lock

o Transparent dressing

o Adhesive tape.

PROCEDURE

NURSING ACTION	RATIONALE
Prepare the article.
Observe the cannula site for any redness, enquire about pain. Observe the dressing that it is secure and the site is visible.	Dressing at the cannula sites are the first line of defense against infection and dislodgement.
Perform hand hygiene and don gloves.
Change the dressing if it became insecure or if there is blood or fluid leakage under the dressing.
Carefully remove old dressing always holding the cannula in place.
Loosen the edge of the dressing/tape and remove low and slow in the keeping it close to the skin surface while pulling it back over itself, and supporting the newly exposed skin with the other hand.	Pulling the tape at vertical angle to the skin will pull at the epidermis, increasing the risk of MARSI (medical adhesive related skin injury).
Doff the gloves.
Wash hands and don gloves.
Thoroughly inspect the site of entry of the cannula for any sign of infection.
Clean the skin by alcohol swab for 15 seconds. Use a repeated back-and-forth technique to clean an area of skin.
Scrub the leur lock plug of the cannula with alcohol swab in a circulatory motion for 15 seconds and let it dry for 30 seconds.
Prepare the flush (minimum 2ml) of normal saline. Use a10ml syringe.	The volume of flush should be equal at least twice the volume of the catheter. Use 10ml syringe for flushing to avoid excessive pressure in the lumen and prevent rupture of the catheter.
Flush the IV line using a pulsatile technique (push pause motion).
Document all relevant information in nurse’s record.

REMOVAL OF EXTERNAL JUGULAR CANNULA

ARTICLES

o Non-sterile gloves

o Antiseptic solution

o Dry Gauze

o Transparent dressing

o Adhesive tape.

PROCEDURE

Identify the patient by name and hospital number.
Check for physician order in the medical record.
Stop the infusion solution and disconnect the tubing.
Release the adhesive tape and transparent dressing from the skin.
Withdraw the catheter and apply direct pressure over the insertion area with gauze for at least 5 to 10 minutes.	To prevent the hematoma formation.
Inspect the catheter for fragmentation.
Place a dry gauze with adhesive tape over the IV insertion site.

NM1504a - NASOGASTRIC INSERTION

DEFINITION

A tube is inserted through one of the nostrils, down the nasopharynx, and into the alimentary tract

PURPOSE

· To allow the intestinal tract to rest and promote healing after bowel surgery

· to administer tube feeding and medications to clients unable to eat by mouth or swallow a sufficient diet without aspirating food or fluids into the lungs

· To monitor and treat bleeding in the gastro-intestinal tract

· To remove undesirable substances such as poisons

· To obtain specimen

· To treat an intestinal obstruction

· To prevent stress on an operated site by decompressing stomach secretion and gas.

ARTICLES

· Towel

· Appropriated sized ryles tube

· Bowl small with water

· Pen light/ flash light

· Tongue depressor

· Lubricant

· Gloves

· Adhesive plaster

· Straight scissors

· Syringe 50 ml

· Mackintosh/Under pad

· Wet swab in a bowl small

· Glass of water

· P^H strip /P^H plaster

· Stethoscope

· Label

· Maggles forceps

· Artery Curved forceps

· Kidney tray-2

PROCEDURE

NURSES ACTION	RATIONALE
Check the physicians order for any precautions such as for positioning or movement	This clarifies procedure and type of equipment required
Identify patient by name and hoapitaI no.
Assess the ability of patient to follow instructions & maintain desired position during insertion	Avoid the risk of aspiration of fluid
Review the patient’s medical history for any nasal lesions, bleeding polyps or deviated nasal septum, platelet count.	May require change in route of nutritional support E.g.orogastric insertion
Assemble all articles near bed side	Organization provides accurate skill performance
Explain procedure to the patient	Reduces anxiety and helps patient to co-operate in insertion of tube
Place the patient in a high/semi fowlers position	Facilitates insertion of tube and reduces risk of aspiration
Place towel across the chest and spread mackintosh under head	Prevents soiling of patient’s dress
Cut the adhesive tape 10cm long	To fix the tube over nostrils
Perform hand hygiene and wear gloves	Prevents contamination from secretions
Measure the length of tube that is from tip of the nose to the tip of the ear lobe and to the tip of xiphoid process and mark with tape.	The measured length approximates the distance from nose to stomach
Clean the nostrils with wet swab if needed and lubricate the tip of the tube about 6-8 inches	Lubrication reduces friction between mucus membrane and the tube
Insert the tube through the nostril to the back of the throat, aiming back down towards the ear.	Following the normal contour of the nasal passage while inserting the tube reduces irritation and the likely hood of mucosal injury
Flex the patient head towards the chest after the tube has passed the nasopharynx	Reduces the risk of tube entering the trachea
Encourage patient to swallow by giving sips of water when possible	Facilitates passage of the tube
Advance the tube 3- 4 inches each time patient swallows until desired length has been passed. Do not force tube
If there are signs of distress such as gasping, coughing, cyanosis pull back the tube for some length and check if patient’s distress is relieved	The tube may have entered the trachea
Perform on of the following measures to check for the placement of tube: Aspirate gastric contents and check PH using litmus paper. Ask the patient to speak. X-ray may be done if necessary. Auscultatory method: place the stethoscope over the client’s epigastrium and inject 5-10 ml of air in a 50cc syringe into the tube and listen for a whooshing sound.	It indicates the tube is in stomach. Sound indicates placement of tube in the stomach.
Examine the patients mouth using tongue depressor and flash light	The tube may be coiled in the mouth
Secure tube with tape and avoid pressure on nares	Constant pressure of the tube against the skin and mucous membranes causes tissue injury
Make patient comfortable in bed	Promotes comfort and integrity of oral mucous membrane
Discard the waste as per JMMCRI policy and replace articles. Remove gloves, and wash hands.	Reduces transmission of micro-organisms
Document all relevant information in nurse’s record. Maintain intake output chart	Documentation provides coordination of care

NASOGASTRIC TUBE FEEDING

DEFINITION

A nasogastric tube feeding is providing liquid nourishment through a tube into the intestinal tract, when client is unable to take food or any nutrients orally.

PURPOSE

Ø To provide adequate nourishment to patients who cannot feed themselves/ through mouth

Ø To administer medication

Ø To give large amounts of fluids for therapeutic purpose

ARTICLES

Ø Crushed Medicine

Ø Formula Feed/Feed To Be Administered

Ø Kidney Tray

Ø Towel

Ø Measuring Cup

Ø 50 Ml Syringe

Ø Water In A Container

Ø Mackintosh

Ø Gloves

Ø Stethoscope

PROCEDURE

NURSES ACTION	RATIONALE
Check physician’s order, assess the need for feed and identify the patient	Checking the doctor’s order confirms the type of feeding solution, route and prescribed delivery time
Explain procedure to patient	Proper explanation allays anxiety and ensures cooperation
Assess for food allergies, time of last feed bowel sounds and lab values	Proper assessment will prevent risk of complication
Assists patient to high/semi fowlers position	It enhances gravitational flow of feed through tube and prevents risk of aspiration
Spread towel over patient’s chest and mackintosh under patient’s head	Protects patient and bed linen from soiling
Wash hands and wear gloves and attach syringe to nasogastric tube	To prevent the spread of infection
Aspirate the stomach content, if there is doubt about the tube placement, inform physician and obtain an order of X-ray if necessary.	If residual gastric contents exceed 100ml withhold feed and notify physician
If the tube placement confirmed in stomach, pinch the feeding tube and attach barrel of feeding syringe to tube	Pinching of feeding tube prevents air from entering the stomach and causing distension
Pinch the tube, fill syringe barrel with water and allow fluid to flow in by gravity, by raising barrel above level of patients head
Pour feeding to syringe barrel and allow it to dry by gravity. Keep on pouring feed/formula to barrel when it is three quarters empty. Pinch tube whenever necessary to stop when pouring	Prevents air from entering tube
After feeding is completed, flush tube with at least 30ccof plain water	Prevents clogging of feeding tube
After tube is cleared, pinch the tube and close the end of feeding tube	Prevents leakage
Rinse equipment thorough with warm water and dry.	Prevents bacterial concentration
Keep head of bed elevated for 30-60 min after feeding.	Prevents aspiration
Remove gloves and wash hands.	Reduces risk of transmission of micro-organism
Document type and amount of feeding, amount of water given in the I/O chart. Also record amount, color and consistency of aspirated fluid.	Provide accuracy and accountability in care
Monitor for breath sounds, bowel sounds, gastric distension, diarrhea, constipation, and intake and output	Evaluate for aspiration effects on GI system and therapeutic effect of feeding
Instruct the patient to notify the nurse if he experiences sensation of fullness,, nausea or vomiting

NASOGASTRIC TUBE REMOVAL

PURPOSE

· When the nasogastric tube is unnecessary.

· To prevent complication

ARTICLES

· Gloves

· Kidney tray

· Sterile gauze pieces

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician’s order for removal of NG tube	Avoids errors
Identify the patient by name and hospital no.	Right procedure is done for right patient
Explain the procedure and provide privacy.	Providing explanation fosters cooperation
Position the patient (fowlers).	For easy removal of the NG tube.
Perform hand hygiene and wear gloves.	Prevents cross contamination.
Remove adhesive tape from patient’s nose.
Clamp the tube by doubling the tube on itself.	Prevents drainage of gastric contents into the pharynx and esophagus.
Instruct the patient to take deep breath and hold it.
Quickly and carefully remove tube while patient holds breath.	Minimize trauma and comfort.
Coil the tube into the kidney tray.
Dispose the waste as per JMMCRI policy	To prepare for the next procedure.
Remove gloves and perform hand hygiene.	Prevents cross contamination.
Record the date, time, and the client’s condition on the chart. And be alert for complains of discomfort, distension, or nausea after removal.	Documentation provides coordination of care giving signature maintains professional accountability.

NM1505a - URINARY CATHETERIZATION

DEFINITION

Introducing a catheter into the urinary bladder through urethra using aseptic technique for the purpose of emptying the bladder

PURPOSES

To relieve discomfort due to bladder distension or to provide gradual decompression of a distended bladder

To assess the amount of residual urine if the bladder empties incompletely

To obtain sterile urine specimen

To empty the bladder completely prior to any procedure

ARTICLE

A sterile tray containing

Bowl small-2

Artery Curved forceps

Sponge holder forceps

Sterile gauze

Drape towel

Hole towel

Kidney tray

A Tray Containing

Sterile Catheter Appropriate Size

Sterile water

Syringe -10cc

Lubricant

Antiseptic Cleansing Solution (10% iodine/normal saline)

Urometer/ Urobag

Sterile Gloves, Mask &Surgical Gown

Adhesive Tape

Sterile bottle (for specimen)

Label

Surgical clippers

Mackintosh/ under pad

Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check physician’s order
Identify patient carefully	Ensures the right procedure is done on right patient.
Explain procedure to patient & provide privacy	Gain co-operation and allay anxiety.
Place the client in appropriate position and drape all areas except the perineum A) Female: Dorsal Recumbent Position With Legs Flexed. B) Male: Supine, Thighs Slightly Abducted	Provide comfort
Establish adequate lighting	Necessary to see urinary meatus clearly
Wash hands and wear mask and gloves	Prevents infection
Cleanse the perineal area Female- separate labia majora with sterile gauze by using non-dominant hand. Wipe using sterile gauze by using nondominant hand	Adherence with the principle of cleaning centre to periphery
Wipe the areas in the following sequence (female) a. Labia Minora-inner Side then Outer Side b. Labia Majora- inner Side then Outer Side. c. Mons Pubis By Zig-zag Manner d. Thigh Inner Side e. Rectum	Adherence with the principle of cleaning centre to periphery
Wipe the area in the following sequence(males) Glans penis Shaft of penis using downward strokes toward the pubic area Mons pubis by zig-zag manner Thighs inner side Tube Rectum
Always clean the farther side and then the nearest side.
Wash hands and change gloves.
Take the hole towel and spread it	Minimal exposure of the patient
Lubricate the catheter tip (1-2 inch for females and 6-7 inch for males)	Facilitates catheter insertion and reduces tissue trauma
Insert the catheter. Grasp the catheter firmly 2-3 inch from the tip. Ask the client to take slow and deep breath and insert the catheter as the client exhales. Female Ask the patient to bear down gently to help expose urinary meatus. Advance catheter 5 to 7.5 cm until urine flows from catheter, then advance an additional 5cm. Male Hold penis perpendicular to body and pull up slightly on shaft. Ask patient to bear down gently and slowly insert catheter through urethral meatus. Advance catheter 17 to 22.5 cm until urine flows from catheter. Advance the catheter 2 inches farther after the urine begins through it; to be sure it is fully in the bladder	The sphincter relaxes and the catheter can enter the bladder easily It ensures placement in the bladder
Inflate the catheter balloon with sterile water	The balloon anchors the catheter in place in the bladder
Pull gently on the catheter after balloon is inflated to feel resistance	Improper inflation can cause patient discomfort and mal-positioning of the catheter
Attach catheter to drainage system	Closed drainage system minimizes the risk for microorganisms
Secure the catheter tubing to the inner thigh	To reduce the manipulation of the catheter and thereby reducing the risk of infection
Label the catheter and the uorbag /urometer.
Wipe the perineal area of any remaining antiseptic or lubricant	Neat appearance
Assist the patient to be in comfortable position
Send the specimen to the laboratory immediately with dully filled laboratory requisition form.	To obtain accurate diagnosis.
Replace article & discard the waste as per JMMCRI policy	Prevents contamination
Remove gloves and wash hands	To reduce the spread of micro-organism
Document all relevant information in nurse’s record (size of catheter, urine consistency, color of urine, first output to be mentioned, patient response)	Provides continuity in care and professional accountability

CARE OF URINARY CATHETER

MEANING

Cleansing the urethral meatus, the skin surrounding the catheter insertion site and perineum for patients with retention catheter

PURPOSES

· To promote patient comfort

· To reduce the chances of developing urinary tract infection

Sterile tray containing

· Artery Curved forceps

· Thumb forceps

· Gauze piece

· Bowl small

Clean tray containing

· Antiseptic lotion/normal saline

· Mackintosh/ Under pad

· Glove

· Kidney tray

· Adhesive tape & straight scissors

PROCEDURE

NURSING ACTION	RATIONALE
Prepare necessary equipment and supplies	Ensures efficiency and smooth functioning
Explain procedure to the patient	Reduces anxiety and promotes co-operation
Provide privacy	Maintains patient self-esteem
Do hand washing	Reduces transmission of micro-organism
Position patient Female-Dorsal recumbent position with legs flexed. Male-supine position.	Ensures easy access to perineal area
Place water proof pad/mackintosh under patient	Protects bed linen from soiling
Drape sheet over patient exposing only perineal area	Prevents unnecessary exposure of body parts
Wash hands and don gloves	Prevents cross infection
Clean the perineal area with disinfectant/normal saline	Moving from an area where there is less number of organisms to an area where there is more number of organisms will help in preventing spread of infection
Female – separate labia majora with sterile gauze by using non dominant hand	Adhere with principle of cleaning centre to periphery
Wipe using sterile gauze by using non dominant hand
Wipe the areas in the following sequence(females) a. Labia minora- inner side then outer side b. Labia majora-inner side then outer side c. Mons pubis by zigzag manner d. Thighs inner side e. Tube f. Rectum	Adhere with principle of cleaning centre to periphery
Always clean the farthest side and then the nearest side	Adhere with principle of cleaning centre to periphery
Wipe the areas in the following sequence (males) a. Glans penis b. Shaft of penis using downward strokes toward the pubic area c. Mons pubis by zig zag manner d. Thighs inner side e. Tube f. Rectum	Adhere with principle of cleaning centre to periphery
Place patient in safe and comfortable position	Promotes comfort
Dispose of contaminated supplies, doff gloves and wash hands	Prevents spread of infection
Document relevant information (condition of perineal tissue, the time, patients response and abnormalities) in nurses record	Provide data to document procedure and informs concerned others of patient
Maintain the bundle care to prevent catheter associated urinary tract infection (CAUTI).	To prevent the occurrence of catheter associated infections.

REMOVAL OF URINARY CATHETER

MEANING

Removal of an indwelling catheter

INDICATION

Remove the catheter as soon as possible, unless there are appropriate indications for continued use.

ARTICLES

Ø 10 ml syringe

Ø Mackintosh/Under pad

Ø Gloves

Ø Mask

Ø Screen

Ø Kidney tray

Ø Urinal

PROCEDURE

NURSING ACTION	RATIONALE
Check the physician order	Ensure that correct intervention is done
Identify the patient by name and hospital number	Prevents errors
Assemble all articles to the bedside	Conserve energy and time
Provide privacy to the patient	Gets co-operation
Position and drape the patient as for catheterization	Positioning allows access to the site .draping prevents unnecessary exposure
Wash hands and wear gloves	Prevents cross contamination
Remove the leg strap, tape or other device used to secure the catheter	Permits easy removal of catheter
Insert the syringe into the balloon inflation port and aspirate for the entire amount of sterile water used to inflate balloon	Deflation of balloon allows catheter removal
Ask the patient to take several deep breaths. Slowly and gently remove the catheter	Slow deep breathing helps to relax the sphincter muscles. Slow and gentle removal prevents trauma to the urethra
Dispose equipment as per JMMCRI policy	Prevents contamination
Remove gloves and perform hand hygiene	Prevents spread of microbes
Document (type and size of catheter removed, amount of fluid removed from balloon, patient’s tolerance, amount of urine in urinary bag) in nurses record	Helps in future communication
Advice the patient to inform any difficulty in voiding after catheter removal. Advise to drink plenty of water, if there is no restriction. Observe for next micturition and characteristics of urine.	Helps in rectify the complications

NM1506a - CHEST DRAINAGE SYSTEM

Chest drainage tubes are inserted to drain pleural fluid or air, and/or facilitate the re-expansion of a lung. No matter what the reason or underlying cause, chest drainage tubes help to resolve the problems associated with large volumes of air or fluid that have collected in the pleural space.

PRINCIPLES.

Water seal: prevents air from getting into the tubing and pleural space.

Suction: promotes drainage by causing a negative intra pleural pressure

Gravity: allows placement of the collection system below patient’s chest level enabling fluid to flow.

PURPOSES

Assess the amount of pleural drainage.

Drain the air collected in the pleural space.

Maintain pleural pressure.

INDICATION

Hemothorax

Pneumothorax

Tension pneumothorax

Hemopneumothorax

Chylothorax

Empyema

Pleural effusion

Lung &heart surgery

INSERTION SITE

Hemothorax- 4^thto 5^th intercostal space at the midaxillary line

Pneumothorax – 4^th or 5^th inercostal space in the anterior chest at the midclavicular line.

CHEST DRAINAGE SYSTEM

Single Bottle Drainage System: - The chamber serves as a fluid collector and a water seal. During inspiration fluid in the chamber ascends. During expiration fluid in the chamber descends.

Two Bottle Drainage System: - The fluid collects in the collection chamber and the air flows into the water seal chamber, this system is used when larger amount of drainage are expected.

Three bottle drainage system: - If air or fluid needs to be removed with controlled suction, 3 chamber system is used. Usually 15 to 20 cm water pressure is used for adults. Distance below water is equal to negative pressure generated when suction is applied. When the gravity is insufficient or the respiration is weak this system can be used.

FUNCTION

Inspiration

Increase intra pleural pressure

Air & fluid move into the bottle

Intra pleural space become negative

Lung re-expand

Inspiration

EQUIPMENT

ICD tray (sponge holder, Artery Curved forceps, needle holder, scissor, BP handle No: 3, toothed forceps, bowl small, Hand towel and Hole towel).

Chest drainage bottle holder

Chest drainage system

Long and short tubes

Sterile normal saline

Tubing clamp- 2 No (tips covered with rubber)

Sterile dressing set

Suture as per the requirement

Personal protective equipment

Waterproof adhesive tape

Receptacle for soiled disposable items

PROCEDURE

NURSING ACTION	RATIONALE
Explain the procedure to the patient.	Relieves anxiety and patient gains confidence.
Provide privacy.	Reduces embarrassment and promote nurse patient relationship.
Perform hand hygiene and put on personal protective equipment.	Prevents the spread of microorganisms.
Place a waste receptacle/ bag at a convenient location for use during the procedure.	Prevents the spread of microorganisms
Adjust the bed to comfortable working height; usually elbow height of the caregiver.	Prevents back pain and muscle strain.
Place the patient in comfortable position (semi fowler’s)	Provides comfort and prevent strain
Assist the physician to mark the site. (Triangle of safety). It is an imaginary line formed by apex, lateral edge of pectoralis major, lateral edge of latissimus dorsi muscle, and 5th intercostal space. USG helps to identify the loculations and mark the site.	Minimal blood vessels in the triangle of safety area.
Clean the area with antiseptic solution.
Assist the physician to give local anesthesia.
Provide the surgical blade and the Artery Curved forceps to incise the site and pleura.
Prepare the chest drainage tube and assist the physician to insert into the tube.
Clamp the chest drainage tube immediately.	It helps to avoid the immediate evacuation of the content and there by collapse of the lungs.
Connect the tube to chest drainage system and observe for the column movement.	It ensure the position the chest drainage tube.
Ensure that bottle are kept in the bottle holder.	Prevents risk of accidental breakage and falling down.
Place the patient in a comfortable sitting position.	Enables free access to the site.
Maintain bottle/bottles at 0.5-1 m below the patient’s chest.	Prevents water being sucked into the chest.
Release clamps from chest drainage tube.	Prolonged clamping may lead to the development of tension pneumothorax.
Observe for the chest drainage tube and system for water column movement with the patient respiration.
Fix the chest drainage tube with adhesive tube.
Loosely fasten the chest drainage tube to patient clothing.	Prevents dragging the chest drainage tube.
Position the patient comfortably on the bed.
Perform hand hygiene.	Prevents transmission of infection.
Record procedure in medical record.	Act as a communication among staff members.
Continue monitoring the patient.	Help to know the response to new system.

NOTES

· Milking or stripping the chest drainage tube is controversial as it may create excessive negative pressure, so it is not recommended nowadays.

· Extra set of sterile containers and connection should always be available.

· Regular, frequent, staged coughing and deep breathing are important since they increase the intra-pleural pressure and force the air and fluid to drain out of the cavity and thus promoting lung expansion.

· Drainage exceeding 100mL/hour or a change in drainage to a bright red color indicates fresh bleeding and requires immediate notification to the physician.

· Always keep two clamps near bedside, to use in case of accidental disconnection or breakage of the drainage system.

· In case of accidental breakage of bottles, the tube should be immersed in a bottle with sterile saline or sterile water.

· If there is accidental displacement of chest drainage tube, nurse should cover the site with sterile gauze.

CARE OF CHEST DRAINAGE SYSTEM

PROCEDURE

NURSING ACTION	RATIONALE
Perform hand hygiene and don gloves.
Change the dressing if it became insecure or if there is blood or fluid leakage under the dressing.
Observe the chest drainage site for any redness, enquire about pain. Observe the dressing to make sure if it is secure and the site is visible.	Dressing at the chest drainage sites are the first line of defense against infection and dislodgement.
Change the drainage system if it is filled.
Clamp the chest drainage tubing by using two clamps. One clamp is positioned1 ½ to 2 ½ inches from the insertion site and the second clamp is placed one inch down the other one.	Prevents air entering into the pleural cavity
Disconnect the chest drainage system from the chest drainage tube.
Reconnect new chest drainage system.
Watch for repeated fluctuation in the water level in the distal end of the chest drainage tube (tidaling or column movement )	These fluctuations correspond to the patient’s breathing and indicates that the system is patent. Absence of fluctuation indicates that the chest drainage tube is blocked or the lung is re-expanded. This can be confirmed by percussion, auscultation and chest radiography.
Discard the waste as per JMMCRI policy.
Perform hand hygiene.
Document all relevant information in the medical record.

ASSISTING WITH REMOVAL OF CHEST DRAINAGE TUBE

EQUIPMENT

· Suture removal set

· Dry gauze

· Sterile disposable gloves

· Adhesive tape

· Elastic bandage

· Straight scissors

· Chest drainage tube clamp

· Antiseptic solution

· Normal saline

· Kidney tray

· Disposable water proof absorbing pads

PROCEDURE

NURSING ACTION	RATIONALE
Ensure that lung re-expansion is complete expansion by noting the signs. a. Chest X-ray reveals total lung re-expansion. b. Water-seal fluctuation has stopped for 24 hours. c. Drainage is declared to less than 30mL/day. d. Percussion reveals normal resonant note.	Pleura of the expanded lung seals the holes on the internal tip of the chest drainage tube, halting fluctuation in the water seal. This can be expected 2-3 days after chest drainage tube insertion Drainage has been reduced, allowing the lungs to re-expand Normal percussion sound occurs with re-expansion.
Clamp chest drainage tube for 12-24 hours before removal or as ordered by the physician. Assess for changes in vital signs, chest pain and level of apprehension.	Physician orders tube clamping before removal to assess patient’s tolerance
Explain procedure.	Reduces anxiety and promotes patient’s cooperation.
Administer prescribed medication for pain relief about 30 minutes before procedure	Reduces discomfort and relaxes patient.
Assist patient to sit on edge of bed or to lie on the unattached side.	Physician prescribes patient’s position to facilitate tube removal
Support patient physically and emotionally while physician removes dressing and clips or sutures.	Reduces anxiety and promotes cooperation.
Set an occlusive dressing and sets it side on a sterile field.	Essential to prepare in advance for quick application to the wound upon the tube withdrawal.
Tell the patient to take a deep breath and hold it or exhale completely and hold it	Prevents air from being sucked into chest as the tube is removed.
Physician quickly pulls out the chest drainage tube while patient is holding his breath.	Prevents entry of air through the chest wound.
Quickly applying prepared dressing over the wound and firmly secures it in position with elastic bandages.	Keeps wound aseptic .prevents entry of air into the chest. Wound closure occurs spontaneously. Clips or sutures aid in skin closure.
Assist patient to comfortable position.	Assures that the patient is comfortable
Remove used equipment from bedside with gloved hands.	Assures that the patient is comfortable
Remove gloves and perform hand hygiene.	Reduces transmission of micro-organism
Observe patient for subcutaneous emphysema or respiratory distress during the first few hours after the removal	Provides for early notification of physician if adverse symptoms occur. Chest drainage tube may need to be re-inserted.
Assess patient vital signs and psychological status.	Detects early signs and symptoms of complications.
Check chest dressing for drainage. Record removal of tube, the amount of drainage in the collection bottle, appearance of wound and of dressing and patient’s response. Patient response also should include vital signs and respiratory assessment	Assures occlusion of chest wound. Document procedure and status of wound and dressing .Documents patient’s response.
Obtain a chest X-ray if advised by physician.	Document procedure and status of wound and dressing. Documents patient’s response.

NM1507a – ASSISTING IN INSERTION OF DRAIN, CARE & REMOVAL

DRAINS

DEFINITION

Drain systems are a common feature of post-operative surgical management and are used to remove drainage from a wound bed to prevent infection and the delay of wound healing. A drain may be superficial to the skin or deep in an organ, duct, or a cavity such as hematoma. The number of drains depend upon extend and type of surgery. A closed system uses a vacuum system to withdraw fluid and collect the drainage into a reservoir. Drainage system must be emptied and measured at least once in day and cleaned using sterile technique. Drains are usually sutured to skin to prevent accidental removal. The drainage site is covered with a sterile dressing and should be checked periodically.

PURPOSE

· When abnormal fluid, blood and air collections are present or expected.

SITE

· Usually in compartment that are intolerant to fluid accumulation. (Joints and abdominal spaces)

· In areas with a large blood supply (The neck and the kidney)

· In infected draining wounds.

· In areas that have sustained large superficial tissue dissection. (Breast).

TYPES

· Abdominal drainage kit

· Corrugated drain

· Negative pressure system ( e.g.Romovac, Minivac)

EQUIPMENT

· Suction drain catheter with sharp trocar (bellow unit, tubing and Y connector)

· Suction catheter (10F,12F,14F,16F)

· Corrugated drain

· Radiopaque silicon catheter

· Suture material

· Scissor

· Needle holder

· Needle (18 G)

· Sponge holder

· Artery Curved forceps

· Toothed forceps

· BP handle

· Blade 11

· Adhesive tape

· Dry gauze

· Antiseptic solution

· Bowl small

· Local anesthetic

· Syringe 10cc

· label

· Under pad

· Kidney tray

INSERTION OF DRAIN

NURSING ACTION	RATIONALE
Identify the patient by hospital number and name.
Check surgeon’s order.
Assemble article at patient side.
Assist the surgeon to identify the site.
Perform hand hygiene and don gloves.
Mark the site.
Clean the area with antiseptic solution.
The surgeon inserts the drain catheter to the site with counter pressure applied above skin surface.
Ensure that all holes in the catheter are inside and trim the perforated catheter to the length needed.
Assist the surgeon to lake loose square knot suture.	To immobilize the catheter.
Make sure that the drain catheter should avoid crossing over vascular repair site.
An additional suture passed through the skin through the nearest catheter hole and then back through the skin.	Avoids the displacement of the catheter.
The catheter trocar is attached to a clamped plastic tubing accompanied by a drain.
The other end of the plastic tubing is connected to the reservoir, a drain bag in the low pressure drain and a negative pressure bottle in the high pressure drain.
Assist the surgeon to close the wound and apply an adhesive tape.
On the clamp of the plastic tubing.
Monitor the drainage	The reservoir collect immediately after surgery.
Replace the article and dispose the waste as per JMMCRI policy.
Remove gloves. Perform hand hygiene.
Document all relevant information in the medical record.

Complication

Culture media for bacterial growth.

Increased pressure at surgical site, interfering with blood flow to area.

Pressure on adjacent area.

Local tissue irritation and necrosis (due to bile, pus, pancreatic juice and urine).

CARE OF SURGICAL DRAIN

ARTICLE

· Drainage measurement container

· Non-sterile gloves

· Dry gauze

· Adhesive tape

· Antiseptic swab

· Kidney tray

Safety considerations

· Perform hand hygiene

· Confirm patient

· Explain process to patient

· Listen and attend patient cues.

· Ensure patient privacy and dignity.

PROCEUDRE

NURSING ACTION	RATIONALE
Monitor the drainage.	The reservoir collects blood immediately after surgery. The collection gradually become less red over time. The fluid then becomes yellow with occasional blood clot. The surgeon has to be informed if the reservoir fluids suddenly changes to blood with clots or become milky white.
Perform hand hygiene	Hand hygiene reduces the risk of infection
Wear gloves and goggles.
Milk the drain tube. Hold the tube at the skin insertion site with non-dominant hand. Then milk the tube with dominant hand by gently squeezing between the thumb and index finger and moving along the reservoir. The fluid should run along the tube with the finger into the reservoir.	Clot formation causes a sudden drop in fluid flow or fluid leak around the insertion site.
Monitor the site for swelling or tenderness.
Instruct the patient to have bath after 48 hours.
Clean the site with soapy water and pat to dry.
Change the dressing at the drain site daily.
Keep a folded gauze below the drain site and secure it with an adhesive tape.
Look for the signs of infection at the drain insertion site like pain, increasing swelling, redness, pus discharge, foul-smelling discharge, or systemic signs like fever.
Emptying a closed wound drainage system
Clamp the tube
Maintaining sterile technique, remove plug from pouring spout as indicated on drain.	Open plug pointing away from your face to avoid an accidental splash of contaminated fluid. The vacuum will be broken and the reservoir will expand.
Gently tilt the opening of the reservoir toward the measuring container and pour out the drainage.	Pour away from face to prevent exposure of body fluids.
Place drainage container on bed or hard surface tilt away from the face and compress the drain to flatten it with one hand. With other hand swab the surface of the port then insert the plug to close the drainage system.	Gently squeezing the drain to flatten and remove all the air prior to closing the spout will establish the vacuum system.
Secure device onto the bed or patient gown. Check patency and placement of the tube	Proper placement of the reservoir allows gravity to facilitate wound drainage.
Ensure that enough slack is present on the tubing, and that reservoir hangs lower than the wound.	Providing enough slack to patient movement prevents tension of the drainage system and pulling on the tubing and insertion site.
Release the clamp.
Note the character of drainage: color, consistency , odor and amount	Drainage counts as patient fluid output and must be documented.
Discard drainage as per JMMCRI policy.
Remove PPE and perform hand hygiene.
Document all relevant information in the medical record.

REMOVAL OF DRAIN

DRAIN REMOVAL

Removal of drain must be ordered by a surgeon. A drain is usually in place for 24 to 48 hours and removal depends on the amount of drainage over 24 hours.

PROCEDURE

STEPS	ADDITIONAL INFORMATION
Confirms that the surgeon order correlates with amount of drainage in the past 24 hours.	Surgeon should specify an amount for acceptable drainage for the drain to be removed
Explain procedure to patient	It decreases patient anxiety about the procedure. Explain to the patient that a pulling sensation may be felt and but will step after the procedure is complete.
Assemble articles at patient bedside. Dressing tray, sterile suture straight scissors or sterile blade, cleansing solution, extra gauze tape, waste bag and PPE.	Organizing articles helps the procedure occur as efficiently as possible for the patient.
Perform hand hygiene.	Hand hygiene reduces the risk of infection.
Wear PPE.	PPE reduces the potential for accidental exposure to blood or body fluids.
Release suction on reservoir and empty, measure and record drainage if >10ml.	Releasing suction reduces potential for tissue damage as drain is removed.
Remove tape and dressing from drain insertion site	Remove tape to allow for ease of drain removal.
Cleanse site	This site prevents infection of the site and allows the suture to be easily seen for removal.
Carefully cut and remove suture anchoring drain with sterile suture straight scissors or a sterile blade.	Snip beneath the suture knot to ensure contaminated suture not brought into the tissue.
Stabilize skin with non-dominant hand	Applying counter pressure to skin near the drain decreases discomfort to the patient.
Ask the patient to take deep breath and exhale slowly; remove the drain as the patient exhales.	It helps the patient for removal of the drain.
Firmly grasp drainage tube close to skin with dominant hand and with a swift and steady motion withdraw the drain .The other hand should stabilize the skin with sterile gauze around the drain site
When pulling out drain, gather up the drain tubing in the hand as its being removed.
Dispose the drain safe
Remove gloves and wash hands	Prevents contamination of the drain site.
Cleanse the drain site with sterile dressing
Assist the patient back to comfortable position and lower bed.	This ensures patient safety and comfort after the procedure.
Measure and discard drain.
Perform hand hygiene	Prevents the spread of micro-organism
Cleanse the drain site and apply a sterile dressing.
Assist the patient in comfortable position and lower bed.	This ensures patient safety and comfort after the procedure.
Discard the article as per JMMCRI policy.	Prevents the spread of micro-organism
Perform hand hygiene
Document output and drain removal
Assess dressing 30 minutes after drain removal	To monitor for excessive drainage.
Document all the relevant information in the medical record

Notes

à Inform surgeon if any of the below is noted.

à Signs of infection at drain insertion site: pain, increasing swelling, redness, pus discharge, foul-smelling discharge, or systemic signs like fever.

à The sudden drop in a fluid collection inside the reservoir.

à A fluid leak or malfunction of the drain system.

à Accidental in injury to tubing.

à Clots from in tubing and drainage is blocked.

à Less than 30ml/day of fluid output for two consecutive days.

à The drain is no longer is secured to the skin with stitches.

NM1601a - DEFIBRILLATION

DEFINITION

Cardiac defibrillation is the act of administering a transthoracic electrical current to a person experiencing one of the two lethal ventricular dysrhythmias, ventricular fibrillation (VT) or pulseless ventricular tachycardia PVT.

Defibrillation produces nearly simultaneous depolarization of a critical mass of a myocardium, causing momentary cessation of all cardiac activity. Under ideal circumstances, a viable site within the heart’s intrinsic electrical conduction system will then spontaneously initiate an electrical impulse that can restore normal propagation of the heart’s cardiac cycle.

Presence of a pacemaker or implanted cardiac defibrillator does not change the indication or performance of the procedure when a shockable rhythm is present.

EQUIPMENT

A cardiac monitor with defibrillation capability.

TECHNIQUE

Place the defibrillator in the defibrillation mode and the defibrillator’s capacitor is charged.

On biphasic defibrillator usual initial energy is between 120-200 joules. On monophasic, it is 360 joules.

Apply conductive gel on the paddles to maximize the trans-cardiac current flow.

Place the defibrillator paddle on the chest with one paddle placed along the upper right sternal border and the other 6-8cm from the left armpit. Alternatively “hands-free” defibrillator pads may be used.

Once fully charged, the scene is checked to make sure that no one is touching the patient or in contact with anything that is touching the patient. Discontinue oxygen administration other than the closed system (ventilator)

Verbalize loudly to clear the area.

The shock button is then pressed, allowing the stored charge to be delivered across the chest from paddle to paddle or hands-free pad to pad.

After 2 minutes of high-quality CPR following the initial defibrillation, electrical rhythm is checked on the monitor to determine if VF or pVT has been terminated. If there is an organized rhythm the pulse is checked to know whether Return of Spontaneous Circulation (ROSC) is achieved.

Patient may be shocked again if VF or pVT persists after two minutes of CPR.

It is important to remember that every successive electrical defibrillation dose should be of equal or greater value until the maximum available dose is reached.

For pediatric patient the initial energy dose delivered for defibrillation to be 2 joule/kg. Subsequent defibrillations can be dosed at 4 joule/kg or higher with a maximum dose of 10 joules/kg. Infant pads are needed if the patient is under 10 kg or less than 1 year of age.

For a patient who is not in cardiac arrest but needs electrical cardioversion for an unstable tachycardic rhythm, synchronized cardioversion is performed instead of defibrillation to treat this rhythm.

For a patient with VT and palpable pulse, who presents with a signs of hypo perfusion and hemodynamic instability, synchronized cardioversion with 100 joules of energy dose is recommended.

To perform synchronized cardioversion, the defibrillator is placed in the “synchronize” mode by pressing the appropriate button on the machine. This causes the monitor to track the “R wave of each QRS complex” that goes by. A synchronizing marker will appear above each QRS complex, indicating that synchronize feature is active.

The appropriate energy level is then selected, and the discharge/ shock button is pressed and held. The defibrillator may not release the shock immediately. Instead, it may wait for the next R wave appear and delivers the shock on the R-wave. This allows the shock to be provided safely away from the T-wave. The recommended energy levels used to perform synchronized cardioversion vary from 50-200 joules.

NM1602a - ELECTROCARDIOGRAPHY

MEANING

The electrocardiogram represents the electrical tracing of the heart and is recorded non-invasively from the surface of the body.

v The ECG represents a graphic recording of the electrical cardiac activity traced on the electrocardiograph paper.

v The fundamental principle behind recording an ECG is,

o It is an electromagnetic force, current or vector with both magnitude and direction.

o When a depolarization current travels toward the electrode, it gets recorded as a positive deflection, and when it moves away from the electrode, it appears as a negative deflection.

o A current of repolarization travelling away from the positive electrode is seen as a positive deflection and towards a positive electrode as a negative deflection.

o When the current is perpendicular to the electrode, it touches the baseline and produces a biphasic wave.

ECG LEADS

v The conventional ECG machine consists of 12 leads divided into two groups. That is limb leads and precordial leads.(chest leads).

v Limb leads are further categorized as standard bipolar limb leads (I, II, III) and augmented unipolar leads (aVL, aVF, aVR). Precordial leads include V1 to V6.

v Limb leads view the heart in vertical plane, and the precordial leads to record the electrical activity in horizontal plane.

EQUIPMENT

· Cardiac monitor or galvanometer

· Electrodes

· Gauze

· Antiseptic swab

· Razors , clippers or a roll of tape

· Skin adhesive gel

· ECG paper

· Tissue

INDICATIONS

· Palpitation, dizziness, cyanosis, chest pain, syncope, seizure and poisoning.

· Symptoms associated heart disease include Tachycardia, bradycardia, and clinical conditions including hypothermia, shock, hypotension, and hypertension.

· To detect myocardial injury, ischemia, and the presence of prior infarction.

· Rheumatic heart disease

· Drowning and electrocution

· Metabolic disorders

· Cardiopulmonary resuscitation

· Detecting pacemaker or defibrillator device malfunction.

· Blunt cardiac trauma

· Congenital cardiac disease

· Electrolyte imbalance and rhythm disorders

· To monitor pharmacotherapeutic effects and adverse effect of drug therapy.

· Perioperative anaesthesia monitoring

PREPARATION

v Obtain history regarding allergies to drugs and adhesive gel.

v Temperature of the room should be kept optimal to avoid shivering.

v Position the patient in supine position.

v Remove any metallic object like jewellery or watch.

v Loosen the dress and identify the electrode site.

v Remove the chest hair and apply the electrocardiographic adhesive gel to the electrodes.

v Limb and precordial leads should be accurately placed to avoid vector misinterpretation.

TECHNIQUE

v The electrocardiogram moves at the speed of 25mm/sec.

v Time is plotted on the x-axis and voltage on the y-axis.

v On the x-axis, 1 second is divided into five large squares, each representing 0.2 sec. Each large square is further divided into five small squares of 0.04sec each.

v The ECG machine is calibrated in such a way that an increase of voltage by one mVolt should move the stylus by 1 cm.

PLACEMENT OF ELECTRODES

LIMB LEADS

v It includes 1, 11, 111,aVL,aVR and aVF

v ECG electrodes are designated as RA, LA, RL, and LL. These are usually colour coded

Red- Right forearm arm or wrist

Yellow- Left forearm arm or wrist

Black- Right lower leg proximal to ankle

Green – Left lower leg proximal to ankle=

PRECORDIAL LEADS

These are attached to the surface of the chest.

v V1 Right sternal edge at 4^th intercostal space

v V2 Left sternal edge at 4^th intercostal space

v V4 at the level of fifth intercostal space in the mid-clavicular line.V4 should be placed before V3. V3 placed midway between V2 and V4.

v V6 is placed at the fifth intercostal space in the mid-axillary line.

v V5 is placed between V4 and V6.

v V4 and V6 should be lined up horizontally along the fifth intercostal space.

INTERPRETATION

RATE

v Calculate the rate either by dividing 300 by the number of big squares or 1500 by the number of small squares between two R Waves.

v For an irregular rhythm, count the number of beats, ina 10-second strip and multiply it by 6.

v Normal heart rate is 60-99 beats per minute.

RHYTHM

v The leads 1,11,aVF and V1 for rhythm, it involves assessment of

Presence or absence of regular P waves

Duration of QRS complexes

Correlation between QRS complex and P wave

Morphology of P wave

Regular or irregular rhythm

v Regular rhythm ECG has regular P wave preceding a QRS complex in a regular rhythm.

CARDIAC AXIS

v It refers to the direction of heart’s depolarization wave front in the frontal plane.

v Typical cardiac axis is between (-30 ⁰ -90 ⁰).

v Estimate the axis by looking at lead 1 and aVF.

v Left axis deviation (0-90 degrees) is defined by the presence of positive QRS in the lead 1 and negative in lead aVF.

v Right axis deviation (90-180 degrees) is defined by the presence of negative QRS in the lead 1 and positive in lead aVF.

v If both QRS complexes are negative in leads 1 and aVF, it is an extreme right axis deviation or indeterminate axis( -90-180 degrees)

P-WAVE

v It represents atrial depolarization.

v As atrial depolarization initiates by the SA node located in the right atrium, the right atrium gets depolarized first, followed by the left atrial depolarization.

v Its duration should not exceed three small squares in width and 2.5 small squares in height.

v Abnormal P wave may indicate atrial enlargement.

PR INTERVAL

v It represents the time from the beginning of atrial depolarization to the start of ventricular depolarization and includes the delay at the AV node.

v The average interval is 3-5 small squares.

v Long PR interval may indicate first degree AV block.

HEART BLOCK

v Any obstruction in the normal pathway of electrical conduction.

v Their anatomical location can be categorized as sinus node, atrioventricular node or bundle branch blocks.

v Sinus node or sino atrial exit block occurs due to failed propagation of the impulses beyond the SA node resulting in dropped P waves on the ECG.

v Atrioventricular or AV block is a conduction block that can occur anywhere between the SA node and purkinje fibers. There are three variants of AV blocks: first degree, second degree and third degree.

v First degree heart block is defined as prolonging the PR interval by more than 200 milliseconds.

v Second degree heart block is of two types:-

o Mobitz type 1, on ECG it shows a progressive prolongation of the PR interval, and then suddenly, a P wave is not followed by a QRS complex.

o Mobitz type 2, there is a dropped beat without the progressive lengthening of the PR interval.

v Third degree heart block is characterized by a complete electrical dissociation between atria and ventricles, resulting in the atria and ventricles beating at their intrinsic rates.

v Bundle branch block results from the conduction block of either left or right bundle branches.

v The right bundle branch block is represented on the ECG by the presence of a widened QRS complex greater than 0.12seconds, along with RSR pattern in V1 and V2.

v The left bundle branch block is represented on the ECG by widened QRS complex greater than 0.12 seconds, broad or notched R wave with prolonged upstroke in the leads V5, V6, I and aVL, along with ST-segment depression and T-wave inversion, and reciprocal changes in lead V1 and V2.

SEPTAL Q-WAVE

v Q wave often appears as a tiny negative deflection in leads I,aVL, V5 and V6.

v It represents the depolarization of the interventricular septum. Its amplitude is not more than 0.1mV, so septal depolarization is not always visible on the ECG.

R WAVE

v It is the tallest wave of the QRS complex, representing the electrical stimulus as it passes down the ventricles during depolarization.

v The R wave progressively increases in amplitude, moving right to the left in precordial leads.

v A reduced R-wave progression may be due to inaccurate lead placement, left ventricular hypertrophy and anteroseptal MI.

S WAVE

v It represents the final depolarization of the purkinje fibers.

v It is the downward deflection after the R-wave.

ST SEGMENT

v It depicts the end of ventricular depolarization and the beginning of the ventricular repolarization.

v The average duration of the ST segment is less than 2 –3 small squares.

v ST segment is an isoelectric line and lies at the same level of as PR interval.

T WAVE

v It represents ventricular repolarization.

v Its morphology is highly susceptible to cardiac and non-cardiac influences like (hormonal and neurological).

v The suggested criteria for the typical T-wave include the size of one-eighth or less than two-thirds of the size of the R wave and a height of less than 10mm.

QT INTERVAL

v It represents the start of depolarization to the end of repolarization of ventricles.

v The normal QT intervals is less than 400 to 440 milliseconds (ms).

U WAVE

v It is a small wave that follows the T wave.

v It represents the delayed repolarization of the papillary muscles or purkinje fibers.

v It is commonly associated with hypokalemia.

J WAVE (Osborn wave)

v It is an abnormal ECG finding in hypothermia.

v It appears as an extra positive deflection on ECG at the J point of the QRS complex.

NM1603a - SYRINGE PUMP

INTRODUCTION

Syringe pump is designed to deliver drug at a predetermined rate and speed. Syringe pump generally consists of a drum that is attached to a piston. The piston is operated by a motor through a drive screw or worm gear which helps in pushing the plunger of syringe in or out resulting in a smooth flow. The syringe is engaged on a clamp on the frame and the plunger of the syringe is displayed by movement of drum.

PURPOSE

v Designed for précised dosage and infusions, fluids to the patient.

v To provide established volume within a specified time.

EQUIPMENT

Syringe pump.

50cc syringe.

100/200 cm PM line extension.

COMPONENTS OF SYRINGE PUMP

Barrel clamp arm sensor

Syringe flange/ collar sensor

Actuator

Plunger sensor

INFO

Scroll UP/DOWN

YES/START

NO/STOP

Power ON/OFF

Actuator movement (forward/backward)

Infusion light status indicator

Following sites should be avoided

v Edematous areas including lymphedematous limbs (poor drug absorptions increased risk of infection/ exacerbation of edema

v Bony prominences (poor absorption and discomfort).

v Irradiated sites (may have poor perfusion and poor drug absorption).

v Skin folds, sites near a joint and waistband area (movement may displace cannula) and broken skin.

SETTING UP A SYRINGE PUMP

v Check battery power before commencing the infusion.

v Press the INFO key until the battery level option appears on the screen and then press YES to confirm.

v If the battery power has less than 30% life remaining at the start of an infusion then a new battery must be installed.

v Make sure that battery is removed if the syringe pump is not in use.

FITTING THE SYRINGE TO THE SYRINGE PUMP

v When a new syringe is being fitted to the pump, the pump must be SWITCHED OFF using the ON/OFF button.

v Ensure that the syringe is labelled with adequate information regarding drug name, dosage, dilution, date and name.

v Pressing the STOP button does not switch off the pump.

INSERT SYRINGE

v Lift the barrel clamp arm and seat the filled syringe collar/ear and plunger so the back of the collar/ear sits in the central slot.

v The syringe collar/ear should be vertical with the scale on the syringe barrel facing forward.

v Click the syringe plunger into the actuator.

v Lower the barrel clamp arm. The syringe graphic on the screen ceases to flash when the syringe is correctly seated at all 3 points.

v Ensure the barrel clamp arm is down on the syringe.

v Press and hold the ON/OFF key until the pump identification screen appears. The identification screen briefly shows the pump model and software version.

v The LCD display will indicate PRE-LOADING and the actuator will start to move.

v Wait until it stops moving and the syringe sensor detection screen appears.

v During the preloading the actuator will return to the start position of the last infusion programmed. If the actuator is not in the correct position to accommodate this syringe, leave the barrel clamp arm down and use the FF or BACK keys on the keyboard.

v Forward movement of the actuator is limited for safety reason, therefore repeated depressions of the FF key may be required when moving the actuator forward. Backward movement is not restricted.

v The syringe size and brand option will then be displayed on the screen.

v If the syringe size and the brand match the screen message, press the YES key to confirm. If the syringe size and/or brand do not match, scroll with up or down keys until the correct the selection appears, then press the YES key to confirm.

START THE INFUSION

v Check The total volume, duration of infusion (24hours) and rate of infusion (ml per hour) displayed on the monitor.

v Give confirmation by pressing the YES to initiate the infusion.

v Check the line is connected to the pump and patient.

v When the syringe pump is running, the green led indicator flashes and the screen displays.

v If the infusion has not been started and a button has not been pressed for more than two minutes an alarm will sound.

v Lock the keypad to prevent tampering with the pump. Press and hold the INFO key until a chart is displayed showing a progress bar moving from left to right.

v When the keypad lock is activated the INFO, YES/START and NO/STOP buttons are active.

v To deactivate the keypad lock repeat the above procedure. The progress bar will now move from right to left and a beep will be heard.

v To give large amount of fluid use bolus key.

TO CHANGE THE SYRNGE

v The pump must be switched off using the ON/OFF button to ensure the infusion rate is recalibrated once the new syringe fitted.

v Stop the infusion by pressing the STOP button.

v Deactivate the keypad lock by pressing and holding the INFO button.

v Switch the pump OFF by pressing and holding the ON/OFF button.

v Disconnect the infusion line from the previous syringe before removing the syringe from the pump. Normally the syringe will be empty but occasionally it may not be. This ensures that the patient does not receive an inadvertent bolus when the syringe is removed.

v Remove the previous syringe from the pump and attach the new one.

v Check the infusion line is full of fluid and connect it to the new syringe ensuring the leur-lock is fully screwed on to the thread of the syringe tip.

v If there is a delay in re-attaching the syringe to the infusion line, the line should be capped.

v Document on monitoring chart any volume to be discarded from the previous syringe.

TO STOP AN INFUSION TEMPERORILY

v Disengage the keyboard lock by holding down the blue INFO key.

v Pause the infusion using STOP button.

v Switch the syringe pump off using the ON/OFF key.

v Disconnect the line from the cannula.

v Attach a needle free device to the end of the cannula and a sterile universal red bung to the end of the infusion line.

v Do not remove the syringe from the syringe pump.

v The syringe must be clearly labelled so that it can be easily identified.

v Store the syringe pump, syringe and line safely while not in use.

v Document all relevant information in the medical record including the time the syringe pump was stopped and the remaining medication volume in the syringe.

v Clean and disinfect the syringe pump as per JMMCRI policy.

NM1604a - INFUSION PUMP

Infusion pump provide the advantage of controlled administration, the ability to deliver fluids in small volumes or at precisely programmed rates or intervals .It draws fluids from a standard bag of intravenous fluid and controls the rate of flow.

It uses pumping action to infuse fluids, medication or nutrients into patient. It is suitable for intravenous, subcutaneous, enteral and epidural infusions.

COMPONENTS OF INFUSION PUMP

Audible and visible alarm

Pressure indicator

Ultrasonic air detector

Removable peristaltic pump

SMS alarm

Drop/flow rate

Preset or infusion volume

Number lock

Single hand operation

Bolus

Pressure adjustment

IV set lock

Door lock

EQUIPMENT

Infusion pump

IV fluid

IV tubing

IV stand

TYPES OF INFUSION ACCORDING TO THE PRINCIPLES OF WORKING

Gravity infusion devices

Volumetric pumps

Patient controlled analgesia pumps

Syringe pumps

PROCEUDRE

Ensure that the machine is plugged properly into suitable electrical socket.

Switch on the machine.

Prepare the articles needed.

Flush the primary or secondary set to IV pump.

Set rate and volume.

Connect the line to the patient.

Start infusion.

Check safety.

FUNCTIONS OF BUTTONS

START/STOP – It is use to start/ stop the infusion is saline.

ADULT/MICRO – These button is use to set the age of the patient.

ML/MODE – These button is use to set units of infusion.

SET RATE/SET ml/SET TIME (T) – SET RATE is use for setting the rate of saline in ml/hr. SET ml button is use to set ml. SET button is used to set button.

YES/NO – YES button is use for permitting the command and to increase the number numerical value when we are setting rate, ml, time and no button is use for declining the command and also decreasing the numerical value.

ENTER – It is use for access the command.

KVO – It is use to keep vein open.

It is use for going next in the numerical digits when we are setting rate, ml,and time.

CALL – To call the attendant by alarming.

SETTING THE RATE OF FLOW

Formula: - mL X Drop factor = Drops

Hour 60 Minute

Drop factor Drop factor is the number of drops it takes to make up one ml of fluid. For blood (15), for fluids (20).

CAUTIONS WHILE USING INFUSION PUMP

Do not use in high pressure oxygen rooms

Do not operate in rooms where chemicals are stored.

Do not keep in strong sunlight or in any strong light.

Do not operate in areas where air pressure decrease or increase spontaneously

Do not expose it to dust, or in presence of corrosive gas in atmosphere.

Do not use in area where vibration occurs.

Do not use it at hot place or splashing water.

NM1605a - MULTIPARA MONITORING

INTRODUCTION

It displays the patient vital signs such as ECG, NIBP, temperature, oxygen saturation, respiration, CO2, IBP the target patients for monitoring are adults, children and neonates.

MEASURING PARAMETERS

• Electrocardiogram

• Impedance respiration

• Non-invasive blood pressure

• Saturated oxygen from pulse oximeter

• Temperature

• Invasive blood pressure (central venous pressure)

• CO2 partial pressure

OPERATION METHOD

By touching the key directly on the display to change the setting, open or close the window, or scroll the bar.

Do not use sharp objects to operate the touch panel, switch or buttons.

WINDOWS OF MONITOR

The bedside monitor has two types of menu windows:

Simple menu window

Normal menu window

SIMPLE MENU WINDOW

The admit/discharge key

Alarm limits key

Two user specified keys in Review key

Guide key

NORMAL MENU WINDOW

Basic parameters (ECG, RESP/CO2, SpO2, NIBP, TEMP, PRESS)

Review (Trend table, NIBP table, Trend graph, Recall, Full disc, Alarm History)

Patient (Admit/Discharge, Alarm limits, Arryth Alarms)

Setup (Date, Display/sound, Record, system)

Alarm (Suspend monitoring, Suspend alarms, Sleep)

Other (Large numeric, Guide, Interbed, Alarm clock)

PARTS OF BEDSIDE MONITOR

FRONT PANEL

Display /touch screen

Shows monitoring data. Touching a data on the screen changes the displayed screen or settings.

Alarm indicator

Top: blinks or lights when an alarm occurs.

Bottom: blinks in time with the sync sound.

Battery lamp

Indicates the charging of the battery pack.

AC power lamp

Lights when the AC power is supplied to the bedside monitor.

Operation lamp

Lights when the bedside monitor is operated.

Power switch

Turns the power on or off.

REAR PANEL

Handle

For carrying the bedside monitor.

Battery pack holder

Contains the battery pack.

Equipotential terminal

Connect the optimal equipotential grounding lead.

AC source socket

Connect a wall AC outlet with the specified power cord.

RIGHT SIDE PANEL

Alarm output socket

Serial communication socket

RGB (red green blue) output socket

Recorder module holder

Check key

Network socket

ZS socket

USB socket

LEFT SIDE PANEL

PRESS/CO2 sockets

SpO2 socket

ECG/ RESP socket

NIBP socket

TEMP sockets

MONITORING ECG

Select the appropriate disposable electrodes, electrode leads and ECG connection cables.

Connect the selected electrode leads to the ECG/RESP socket with the ECG connection cable.

Attach the disposable electrodes to the patient and attach the electrode leads to the electrodes.

To maintain good contact between the electrode and skin and to obtain a stable ECG, prepare the skin before attaching the disposable electrodes.

Remove the excess hair

Rub the patient skin with dry cotton where the electrodes are to be attached.

Clean the skin if it is dirty before applying the electrodes.

MONITORING RESPIRATION

Connect the electrode leads to the RESP socket with the ECG connection cable.

Attach the disposable electrodes to the patient and attach the electrode leads to the electrodes. Attach the electrodes so that R and F (RA and LL) or R and L (RA and LA) are in positions on either side of the lungs.

When measuring respiration using the impedance method, check (other-impedance measurement) is ON. When this is OFF respiration measurement is not performed is not performed and RESP OFF is displayed on the waveform display.

MONITORING SpO2

Select a SpO2 probe.

Attach the SpO2 sensor to the patient.

Connect the selected SpO2 sensor to the SpO2 socket with the SpO2 connection cord.

Notes

To maintain sufficient blood circulation, keep the measurement site warm by covering it with a blanket or something similar.

Warming the site is especially effective for patients with weak pulse.

Attach the probe to the part such as finger or toe where there is no change in peripheral blood circulation.

MONITORING NIBP

• Select a cuff appropriate for the cuff attachment.

• Connect the selected cuff to the NIBP socket with the air hose.

• When the air hose type is adult or child, select the initial cuff pressure according to the patient.

• Attach the cuff to the patient.

• Do not bend or squeeze the air hose. It may cause noise and prevent correct measurement.

• The cuff should be wrapped around a bare upper arm to obtain the pulse or artery. Wrap the cuff around the limb so the artery mark on the cloth cover aligns with the patient’s artery.

• Do not wrap the cuff around a joint such as the elbow or knee.

• To prevent cutting off the air flow in the cuff tube during measurement, take care that the tube is not bent or under the patient.

• Check the INDEX mark is not within the RANGE marks.

• Change the cuff size.

• When wrapping the cuff, leave enough space that two fingers fit between the cuff and skin. If the cuff is too loose, the skin may get pinched by the inflating cuff and subcutaneous bleeding may occur.

• Place the cuffed upper arm at the same height as the patient’s heart (right atrium). If the cuff is not at the same level as the heart, the weight of the blood affects the blood pressure reading.

• The blood pressure reading decreases when the arm is higher than the heart and increases when lower.

• Measure the blood pressure when the patient is lying on his/her back with arms and legs relaxed.

• Relax the patient if he is conscious. Measurement may not be accurate if the patient’s arm is tense or the patient talks.

• Measurement on the ankle tend to be higher than the measurement on the arm.

• Do not apply pressure or shock to the cuff or air hose during measurement. It May cause noise and the measurement result might be inaccurate.

MONITORING TEMPERATURE

• Select the appropriate probe according to the purpose.

• Connect the selected probe directly to the TEMP socket.

• Attach the probe to the patient.

• Using a probe cover is recommended to prevent infection and contamination.

• The pad prevents the environmental temperature from affecting the sensor temperature and also prevents internal body heat from escaping the attached site so that a stable temperature is obtained.

MONITORING IBP (central venous pressure)

Connect the blood pressure transducer to the multipara meter monitor.

• Connect the IBP connection cord to the PRESS/CO2.

• Perform zero calibration and check that the value is adjusted to zero. Connector wetting prevention and sensor warming up can be performed.

Installing the blood pressure measuring device.

Assembling the blood pressure transducer.

a) Prepare the saline pack.

Prepare flush solution according to the policy.

b) Remove air from the saline pack

Insert the needle at the tip of the micro-drip into the hole on the physiological saline pack.

Pressurize the physiological saline pack with your hand by pressing the flush cap to remove the air from the pack.

When the solution in the micro-dip chamber is about 1/3rd full (stainless needle is in the solution), turn the physiological saline pack upside down.

When the heparin is injected, mix the solutions together.

c) Place the saline pack in the pressure bag and hang the pressure bag on the stand.

d) Fill the saline set, transducer and connecting lines (blood pressure tubes, 3-way stopcock.

Press the flush cap to completely fill the tube with saline solution. Make sure not to leave air bubbles. Tap the bottom part of the micro-dip to remove air bubbles from under the filter.

Fill in the transducer with the saline solution. Remove air bubbles by pressing the flush cap at above the saline pack, then bringing the flush cap down.

e) Replace the white caps with the yellow sealing caps.

f) Pressurize the pressure bag.

Pressurize the pressure bag to 300mm Hg. The solution in the micro-dip chamber is about a third to half full.

Check that the drip rate is 2-4 drips per minute. At the same time, check the solution leaks.

g) Check the setup

After about 30 minutes, check the pressure of the pressure bag and drip rate. Also check that there is no leakage in the circuit.

CLEANING, DISINFECTION, AND STORAGE

• If water accidently gets inside the bedside monitor, stop using it immediately, remove the power plug from the AC outlet and inform.

• Wipe the bedside monitor with a dry cloth before use and allow it to dry completely after cleaning and disinfecting.

• Do not sterilize the monitor.

Surface

• After use wipe with a non-abrasive cloth moistened with 70% alcohol. Dry the surface completely.

• Check the vent periodically for test. If dust has accumulated, remove it with cotton swabs or a vacuum cleaner.

Display

• Touch the function key, which can be registered as a function key in the window.

• This disable the touch keys. No operation will result from touching anywhere on the screen.

• Wipe the display with a dry, soft cloth, a cloth moistened with neutral detergent and wrung out or a cloth moistened with 70% alcohol.

• Touch the check key to turn the touch key function on again.

Electrode Leads, ECG and SpO2connection cords

• After use, wipe with a non-abrasive cloth moistened with neutral detergent diluted in water as per JMMCRI policy and wipe with a dry cloth.

NM1606a - CARDIAC OUTPUTMONITORING

Cardiac output is the amount of blood pumped by the heart per minute and is the mechanism whereby blood flows around the body, especially providing to the brain and other vital organs.

METHOD

· Invasive- Intermittent bolus pulmonary artery thermodilution, Continuous pulmonary artery thermodilution.

· Minimal invasive – Lithium dilution CO, Pulse contour analysis (Picco method, Flotrac sensor),oesophageal Doppler, trans- esophageal echocardiography.

· Non-invasive – partial gas breathing, thoracicbio impedance, and bio reactance, endotracheal cardiac output monitor (ECMO), Doppler method and photoelectric plethysmography.

Minimal invasive cardiac output monitoring (Pulse contour analysis)

It is based on the principle that area under systolic part of the arterial pressure wave form is proportional to the stroke volume. In this method the area is measured post diastole to end of ejection phase divided by aortic impedance that measures stroke volume.

Flotrac is a pulse contour device and requires only an arterial line (femoral or radial). The system does not need any external calibration, is operator independent and easy to use. Good arterial waveform quality is a prerequisite for accurate reading of cardiac output.

EQUIPMENT

IQ sensor set

Non-vented caps

IV pole

IV fluid

IV set

Pressure bag

Pressure cables

STEPS

1. Turn the monitor and connect the pressure cable to the monitoring platform.

2. After entering patient demographics select minimally-invasive technology then select start monitoring.

3. Using aseptic technique, remove the sensor and kit from the sterile packaging.

4. Ensure that all connections are secure but are not overtightened. Replace all vented caps on side ports of the stopcocks with non-vented caps.

5. Mount the sensor or an IV pole using the appropriate clamp and holder.

6. To remove air from the IV flush bag, first invert IV bag. Spike the bag and keep the drip chamber upright. Ensure all air has been removed. Insert the IV bag into the pressure bag and hang on the IV pole (do not inflate).

7. Do not pressurize the bag to prime the system – use gravity only. Flush he sensor device by pulling the snap- Tab device, while holding the pressure tubing in an upright position until the column of fluid reaches the end of the tubing.

8. Pressurize the IV bag until it reaches 300mmHG, then fast-flush the sensor and tap on the tubing and stopcocks to remove any residual bubbles.

9. Plug green connector from the sensor to the pressure cable.

10. Plug red connector from the sensor to the bedside cable.

11. Connect the tubing to the arterial catheter.

12. Level the stopcock to the phlebostaticaxis.Thephlebostatic axis (PA)is defined as the intersection of a vertical line (A) drawn from the 4^th intercostal space at the right edge of the sternum with a horizontal line (B) drawn through the midpoint of a line going from the anterior to the posterior aspects of the chest. It is important to keep the stopcock level tot eh phlebostatic axis at all times to ensure accuracy of cardiac output.

Phlebostatic axis

13. To zero turn the stopcock off to the patient and open to air

a. Hold down the zero button on the pressure cable untilthe zero and waveform screen appears.

b. Next, hold down the zero button until a tone is heard to complete zeroing or select the Quick zero button to pull up the zero screen, then select zero.

14. Open the stopcock back to the patient and confirm waveform is present.

15. Cardiac output data will be displayed every 20 seconds.

Results

· Graphical trend screen- It depicts the numericals and waveform data of patient vital signs.

· Animated physiology screen – it depict the real time change occurring in patient by delivering visual and numeric parameters.

· Cockpit screen – combines large and easy to read with specific colour parameters and alarms to clearly indicate patient status and monitoring needs.

NM1607a - C-ARM OPERATION

INTRODUCTION

A mobile c-arm is a medical imaging device that is based on X-ray technology and can be used flexibly in various operation theatres. The name is derived from the C-shaped arm used to connect the X-ray source and X-ray detector to one another.A C-arm comprises of a generator and an image intensifier or flat panel detector. The C-shaped connecting element allows movement horizontally, vertically, and around the swivel axes, so that X-ray images of the patient can be produced from almost any angle.

COMPONENTS

A general portable system is usually made up of three parts

X-ray generators

Imaging system

Workstation unit

X-ray generator

It is placed inside the frame here the C-arm is mounted. It can be directly controlled by the workstation unit and the operator can even modify the operation of the system in real-time. Even with an increased x-ray power, there is a complete flexibility in imaging and since the exposure time is less, the risk involved here is almost null.

Imaging system

It has the ability to perform multiple movements in a single procedure. This entire system is very much compact and light in weight so that they will allow multiple positioning along with a wide range of motion. However, they remain firm in the mounted position and there is zero possibility of misalignment in between the procedure.

Workstation Unit

It contains multiple handles enabling movements and positioning, switches that control power supply and light exposure, a cable hanger, controls for radiographic and fluro settings, several connecting cables, hard disk and writers, advanced image enhancement software to reduce noises, contrast/bright controls, monitors, zoom control and a brake pedal.

PARTS OF C-ARM

a. Image intensifier

b. Camera

c. Optical coupler

d. Collimator

e. X-ray tube

f. Rotational joint

g. Brake

h. X-ray generator

i. Horizontal travel

j. Foot switch

k. Dual monitor display

l. Printer

m. Monitor display system

PRECAUTION BEFORE C-ARM OPERATIONS

a. Protection of the embryo or fetus during radiological examination or treatment of women known to be or possibly pregnant.

b. Sensitive body organs (e.g. lens of eye, gonads) must be shielded whenever they are likely to be exposed to or be in close proximity to the working beam. This is because, stray radiation can also be harmful.

c. Acute skin burns.

d. Acute hair loss.

e. Chronic radiation injury.

CLEANING

Enameled parts and aluminum surfaces

Clean with a damp cloth and mild detergent. Dry with woolen cloth.

Chrome parts

By rubbing down with dry woolen cloth.

Patient straps

Straps can be washed and sterilized as per manufacturer’s instructions. The straps will withstand the temperature up to 300⁰F (148.9⁰C).

DISINFECTION

a. All parts of the equipment, including accessories and connecting cables, can be disinfected by wiping them with a cloth dampened with disinfectant.

b. Never use corrosive or solvent disinfectants.

c. If non-flammable, non-explosive spray disinfectants are to be used, the equipment must first be switched off and allowed to cool. This prevents convection currents drawing disinfectant mist into the equipment.

d. Plastic sheeting must be used to cover the equipment thoroughly following which disinfectant spraying can take place. Once all traces of the disinfectant vapor have dispersed, the plastic sheeting can be removed and the equipment itself can be disinfected in the recommended way.

POSITIONING OF A PATIENT FOR A CARDIAC PROCEDURE

• Move the tabletop to the non-tilted/non-pivoted position.

• Set flat detector’s source to image distance (SID) to maximum.(approximately 100cm).

• Adjust the tabletop to a convenient height for transfer of the patient on to the table.

• Place the patient on the table in the preferred position. This being in the supine position with the head as close as possible to the head end of the tabletop.

• If applicable move the L-arm longitudinally such that the region of interest is under the flat detector.

• Pivot the C-arm stand so it is in line with the table.

• Adjust the table to a convenient height.

• Adjust the C-arm rotation and angulations for the required projections.

• For the further positioning of the Region of Interest, use the table movements (horizontal float and table height) and if necessary reposition the patient on the tabletop.

• Adjust the C-arm rotation and angulations for the required projection.

• If applicable, rotate the flat detector to the desired position (portrait/landscape).

• Move the flat detector as close as possible to the patient.

POSITIONING OF A PATIENT FOR A VASCULAR PROCEDURE

• Move the tabletop to the non-tilted/non-pivoted position.

• Set flat detector’s source to image distance (SID) to maximum.(approximately 100cm).

• Adjust the tabletop to a convenient height for transfer of the patient from the trolley or bed on to the table.

• Place the patient on the table, this is usually in the preferred (standard) position but may differ as required.

• Move the tabletop into fully extended position away from the C-arm.

• Move the L-arm to position the X-ray tube under the table.

• Pivot the C-arm into the +90⁰(nurses-side) or -90⁰ (doctor side) position.

• Adjust the table to a convenient working height.

For further positioning of the region of interest (ROI), use the table movements (horizontal float and table height) and if necessary reposition the patient on the tabletop.

• Adjust the C-arm rotation and angulations for the required projection.

• If applicable, rotate the flat detector to the desired position (portrait /landscape).

• Move the flat detector as close as possible to the patient.

POSITIONING OF A PATIENT IN SUPINE

• Position the patient on the tabletop and adjust the tabletop to a convenient working height. For convenience the patient should be placed with his/her head at the end of the table.

• Position the tabletop under fluoroscopy so that the region of interest is in the centre of image.

• Adjust the height of the tabletop under lateral fluoroscopy until the region of interest is in the centre of image.

• Position the stand to the angle best suited to the examination.

• Move the flat detector to the minimum distance from the patient to ensure optimum image quality and minimum AK(R).

RADIATION: PROTECTIVE CLOTHING

Lead Gloves

60-64% protection at 52-58 KV.

Eye protection

0.15mm lead-equivalent goggles provide 70% attenuation or radiographic beam.

Thyroid shield (Thyroid collar) (0.5mm)

2.5-fold increase in scattered radiation.

Lead apron (0.5mm)

AP: 16 fold decrease in scattered radiation. Lateral: 4-fold decrease in scattered radiation.

RADIATION MONITORING SYSTEM

TLD Badge (Thermoluminescence Dosimeter)

Ø It is based on phenomenon of thermos luminescence, the emission of light when certain material are heated after radiation exposure.

Ø It is used to measure individual dose from x ray, beta particles and gamma radiation.

Ø Response is directly proportional to the amount of radiation absorbed.

Ø TLD badge must be calibrated before use.

Ø TLD badge should be worn at chest position.

Ø TLD badge is changed in every 3 months/ when the person exposed to large amount of radiation.

Ø TLD badge should be stored away from light, radiation and dust when it is not used.

Ø Response of the TLD material is affected by their previous radiation history and thermal history, the material must be annealed to remove the residual effect. Disc is reusable after proper annealing.

Ø This card mainly is enclosed by a paper wrapper.it stores user’s personal data and period of use is written.

Ø TLD card is made by aluminium sheet covered coated by nickel layer.

Ø TLD cassette it is made of high impact plastic (polythene). There are three files corresponding to each disc. These filters are used to make TLD disc energy independent.

Ø 1^st disc consists of Cu and Al combination filter window and record x and gamma radiation.

Ø 2^nd disc consists of plastic (Perspex) window and record X-ray, gamma ray and hard beta particles.

3^rd disc has no filter and can record all radiation.

Ø TLD badge can measure exposure as low as 10 microsievert.

Ø TLD badge can cover a wide range of the dose from 10 mR to 10000R with the accuracy of +/- 10 percent.

APPLICATION OF C-ARM SYSTEM

Various studies including but not limited to digestive, cardiac, ortho, reproductive and blood circulation systems.

If there is a need to place needles or stents during complicated surgeries, C-arm will be a handy choice.

During surgeries, the real time of the gall bladder, liver, bone and several structures can be obtained. Multiple views of the same part are possible, thus enabling the systems tore construct a 3D model of the inner parts later.

Surgical navigation is one of the primary applications and they aid in verifying the placement of all types of implants devices in the patient.

C-arm systems can also guide a needle placement procedure mainly while injecting anesthetic medicines. They can identify the joints and medication can be inserted perfectly onto the required shoulders and knees without damaging the other structures.

NM1610 - HFNC

HIGH FLOW NASAL CANNULA OXYGEN THERAPY

High flow nasal cannula oxygen therapy is a recent technique delivering a highflow of heated and humidified gas.It delivers high fraction of inspired oxygen (FiO₂), generates a low level positive pressure and provides washout of dead space in the upper airways, thereby improving the mechanical pulmonary properties and unloading inspiratory muscles

INDICATION

· Acute hypoxemic respiratory failure

· Post –surgical respiratory failure

· Acute heart failure/pulmonary edema

· Hypercapnic respiratory failure

· Pre and post extubation oxygenation

· Obstructive sleep apnoea

· DNI patients

CONTRAINDICATION

· Decreased level of consciousness (no response, agitated, uncooperative)

· Claustrophobia

· Airway obstruction

· Nasal Obstruction, Nasal bleeding, Facial injury

· A lot of sputum

· Risk of aspiration

· Unstable hemodynamics (shock,intractable arrhythmia, post-CPR )

· Respiratory arrest

EQUIPMENT

A humidifier with integrated flow generator that delivers high flow of warmed and humidified oxygen to spontaneously breathing patients through a variety of patient interfaces.

FLOW RATE

2-60L/Min

PARTS

· Nasal high flow system

· Heated breathing tube & Chamber Kit (auto fil water chamber and adapter)

· Interface for adult and pediatric options

· Normal saline - 1000ml

NITIAL STEPS

INSTALL WATER CHAMBER

· Remove the blue port caps from the chamber by pulling the tear tab upwards then remove the bracket holding the water supply tube.

· Fit the supplied adapter over the two vertical ports on the chamber and push on fully then clip the water supply tube into position.

· Fit the water chamber to the unit by pressing down the finger guard and sliding the chamber on, carefully aligning with the blue chamber port ends.

· Push the chamber on firmly until the finger guard clicks into place.

CONNECT THE WATER BAG

· Attach the sterile water bag to the hanging bracket 20cm (8”) above the unit, and push the bag spike into the fitting at the bottom of the bag.

· Open the vent cap on the side of the bag spike.

· The chamber will automatically fill to the required level and maintain that level until the water bag is empty.

· Check that water flows into the chamber and is maintained below the maximum water level line. If the water level rises above the maximum water level line, replace the chamber immediately.

Flow Setting/ Usage Time

(2-litre sterile water bag, at 37⁰C target temperature)

L/min

Hrs

378

151

INSTALL HEATED BREATHING TUBE

· One end of the heated breathing tube has a blue plastic sleeve. Lift the sleeve and slide the connector onto the unit. Push the sleeve and slide the connector onto the unit. Push the sleeve down to lock.

SELECT PATIENT INTERFACE

· There are 3 types of patient interface.

o Nasal cannula

o Tracheostomy interface

o Mask interface adapter

Interface	Temperature (⁰C)	Flow rate (L/min)
Pediatric nasal cannula	34	2-25
Adult nasal cannula	34-37	10-60
Tracheostomy interface	37	10-60
Mask interface adapter	31-37	10-60

· Low temperature ambient conditions may prevent the unit from reaching a 37⁰C target temperature setting at high target flow settings. In these cases, consider decreasing the target flow setting.

Interface color	Flow Rate
Yellow	2L -10L
Purple	up to 20L
Green	up to 25L
Orange	Up to 60L

SWITCH ON UNIT

· Plug the unit’s power cord into the mains utility power socket. The connector at the other end of the power cord should be well secured to the rear of the unit.

· Switch on the unit by pressing the On/Off button.

CHECK DISINFECTION STATUS

· Green light on the screen indicated the machine is safe for use on a new patient.

· Orange light indicates the machine has not been cleaned or disinfected since last use.

WARM UP

· The unit will begin to warm up.

· Summary screen shows current output dew-point temperature, flow and oxygen values.

JUNIOR MODE

· Hold the mode button for 5 seconds.

· The target settings for the dew point temperature and flow will be changed automatically. The colorful icons in the corners of the screen indicate that this unit is in junior mode.

CONFIGURE TARGET SETTINGS

TARGET DEW-POINT SETTINGS

· There are three target dew-point temperature settings.

o 37⁰C

o 34⁰C

o 31⁰C

· To change the target dew-point temperature setting

o Hold the up and down buttons for 3 seconds to unlock the setting.

o The lock will disappear and be replaced by an arrow showing the minimum and maximum accessible settings.

o Press the up and down buttons to choose the new settings.

o When you have finished, press the mode button to lock the setting again.

o The lock will reappear.

· Press the mode button to move on the next screen.

TARGET FLOW

· Flow rate can be adjusted from 10L/min and 60 L/min, in increments of 1 L/min (10-25L/min) and 5 L/min (25-60 L/min).

· Junior mode is preset one.

OXYGEN

· The inbuilt oxygen analyzer determine the oxygen fraction of the delivered oxygen.

· The machine should be switched on before connecting oxygen.

· Connect the output from the oxygen source to the oxygen inlet port on the side of the unit. Push the oxygen tube firmly onto the connection port.

· To ensure that oxygen enters the machine correctly, the oxygen inlet port must be fitted properly to the filter holder and the filter holder must be fitted properly to the machine.

· Adjust the level of oxygen from the oxygen source, until the desired oxygen fraction is displayed onscreen. It may take the reading several minutes to settle. Set the oxygen fraction between the maximum and minimum values displayed above and below the arrow.

· Real time oxygen measurement is displayed when oxygen>25% and oxygen <95%. However, note that oxygen fraction below 25% and above 95% will be displayed as 21% and 100% respectively.

· If the oxygen fraction exceeds 95%, the oxygen reading pulse red and the device will beep.

· Ensure to limit the supplementary oxygen level not more than 60L/min, as excess oxygen will be vented into the surroundings.

· The oxygen concentration delivered to the patient can be affected by the changes to the flow setting, oxygen setting, patient interface or if the air path is obstructed.

· When finished, turn of the oxygen source. Remove the output of the oxygen from the oxygen inlet port on the back of the unit.

· The oxygen flow must be turned off when the unit is not operating, so that the oxygen does not build up inside the device.

· Press the Mode button to return to the summary screen.

CONNECT TO PATIENT

· Obtain verbal consent of the patient.

· Wait until the “ready for use” symbol is displayed on the summary screen.

· Connect the patient interface to the heated breathing unit.

· Monitor the flow and oxygen values displayed on the summary screen. Adjust the level of oxygen from the oxygen source as necessary.

· When the patient first uses the unit, the air will feel warm. This is normal. The patient should continue to breathe normally through the nose and/or mouth, or tracheostomy.

DURING USE

· If the “Ready for use “symbol has been displayed for 2 minutes and no button has been pushed in this time, a screensaver will be launched.

· The unit must be placed below head height and flat, this allows condensate to drain towards the water chamber, away from the patient.

· If excess condensate accumulates in the heated breathing tube, disconnect the patient interface from the heated breathing tube, drain the condensate by lifting the patient end of the tube, allowing the condensate to run into the water chamber.

· At higher target flow rates, it may be necessary to first reduce the target flow rate to 30L/min or below, to ensure the condensate drains into the water chamber.

· Minimal local sources of cooling acting on the heated breathing tube, such as a fan to cool the patient, or an air-conditioning unit/vent.

· If condensate persists, consider turning the target temperature down. Note, a lower target temperature will decrease the humidity output of the unit, decreasing the level of condensation.

· Titrate the oxygen flow, once patient is stabilized as per physicians order.

AFETR USE

· Switch off the unit by pressing the On/Off button.

ALARMS

· This unit has visual and auditory alarms to warn interruptions to patient treatment.

Message	Meaning	Affects delivery of:	Delays
Fault	The unit has detected an internal fault and has shut itself down. Switch the unit and then restart. If the problem persists, note the fault code and contact biomedical department.	Oxygen humidity	< 5 seconds
Check tube	The unit cannot detect the heated breathing tube. Check that the heated breathing tube is not damaged and that it is plugged in correctly. If the problem persists, then change the heated breathing tube.	Oxygen humidity	< 5 seconds
Check for leaks	The unit has detected a leak in the system. The most likely cause is that the water chamber has been removed or has not been pushed into place correctly. Check that the heated breathing tube is not damaged and that it is plugged in correctly. Check that the nasal interface is fitted. Check that the filter is fitted.	Oxygen humidity	< 120 seconds
Check for blockage	The unit has detected a blockage in the system. Check the heated breathing tube or patient interface for blockage. Check air filter and filter holder for blockage. Check whether the unit should be in junior mode.	Oxygen humidity	< 10 seconds
O₂too low	The measured oxygen level has fallen below the allowed limit. Check that the oxygen source is still operational and is correctly connected. Adjust the level of oxygen from the oxygen source as necessary.	Oxygen	< 20 seconds
O₂too high	The measured oxygen level has exceeded the allowed limit. Check the unit’s flow rate has been set correctly. Adjust the level of oxygen from the oxygen source as necessary.	Oxygen	< 20 seconds
Cannot reach target flow	The unit cannot flow reach the target flow setting. Check the heated breathing tube or patient interface for blockage. Check whether the target flow setting is too high for the patient interface being used. The oxygen concentration delivered to the patient can be affected by changes to the flow setting. Adjust the level of oxygen from the oxygen source as necessary.	Oxygen	< 120 seconds
Check water	The chamber has a run out of water. When a chamber runs dry, the chamber float may be damaged. Replace the chamber and water bag. To ensure continual humidification, always ensure that the water chamber and/or water bag are not allowed to run out of water.	Humidity	<30 minutes
Cannot reach target temperature	The unit cannot reach the target temperature setting. The most likely cause for this is that the unit is operating at a high flow rate in low ambient conditions. Consider decreasing the target flow setting. The oxygen concentration delivered to the patient can be affected by changes to the flow setting. Adjust the level of oxygen from the oxygen source as necessary.	Humidity	30+/-3 minutes
Check the operating conditions	The unit has detected that it is operating in unsuitable ambient conditions. This alarm may be caused by a sudden change in ambient conditions. Leave the unit running for 30 minutes. Switch the unit off and then restart.	Humidity	60+/-6 minutes

AUDITORY INFORMATION SIGNALS

Signals	Meaning
Ascending sequence of 5 tones	The “Ready for use “symbol has appeared.
Ascending sequence of 3 tones	Activation /deactivation of Junior mode.
Single tone every 5 seconds	Measured oxygen level ≥33% at turn off.
Single tone every 30 seconds	Measured oxygen level>95%.

COMPLICATION

· Epistaxis

· Oxygen toxicity

NM1701a - BASIC LIFE SUPPORT (BLS)

The BLS assessment is a systematic approach to BLS for trained health care providers. This approach stresses early cardiopulmonary resuscitation with basic airway management and defibrillation but not advanced airway techniques or drug administration. Performing the BLS assessment substantially improves a patient’s chance of survival and a good neurologic outcome.

There are two specific chains of survival.

Out of hospital cardiac arrest

In hospital cardiac arrest

If a person collapses at home or in a public place, “out of the hospital cardiac arrest” steps of to be followed are;-

Activation emergency response system

High quality CPR

Defibrillation

Advanced resuscitation

Post-cardiac arrest care

Recovery.

If a person collapses inside a hospital the steps in the chain of survival of “in-hospital cardiac arrest” are

Early recognition and prevention

Activation of emergency response

High quality CPR

Defibrillation

Post cardiac arrest care

Recovery

Chain of survival begins when the rescuer recognizes it as a possible cardiac arrest.

Immediate CPR can double or triple chances of survival after cardiac arrest. If CPR initiation is delayed chances of survival are low due to brain damage. Bystanders who are not trained in BLS are encouraged to provide compression-only-CPR, also called “hands-only-CPR” (push hard and fast in the center of chest).

BLS ASSESSMENT

• If a person collapses, scan scene for safety both for the rescuer and the victim.

• Check responsiveness.

• Tap on both shoulder firmly and shout “Are you ok?” For infant tap the heel of the foot.

• If there is no response shout for nearby help /activate the emergency response system by dialing #123* from extension telephone or call jubilee telephone console from personal phone.

• Check for breathing and pulse.

• Perform the pulse check simultaneously with the breathing check within 10 seconds to minimize delaying CPR. Use 2-3 fingers (excluding the thumb finger) to locate the trachea and then slide the finger into the groove to identify carotid pulse. Carotid pulse is located at the sternocleidomastoid muscle lateral to thyroid cartilage.

• To perform pulse check in an infant, palpate a brachial pulse. Place 2-3 fingers on the inside of the upper arm, midway between the infant’s elbow and shoulder. Then press the fingers to attempt to feel for the pulse for at least 5 but no more than 10 seconds.

• To perform pulse check in a child, palpate carotid or femoral pulse. Place 2 fingers in the inner thigh, midway between the hipbone and just below the crease where the leg meets the torso.

• To check for absent or abnormal breathing (no breathing or agonal gasping) Scan the chest for rise and fall for at least 5 but no more than 10 seconds.

• Agonal gasp is a sign of cardiac arrest. The mouth may be open and the jaw, head or neck may move with gasps. Agonal gasps may sound like a snort, snore or groan.

• If you find no pulse and no breathing within 10 seconds, start CPR, beginning with chest compressions. If there is pulse, start rescue breathing at 1 breath every 6 seconds. Check pulse about every 2 minutes.

HOW TO PERFORM CPR

à Cardiopulmonary resuscitation is an emergency lifesaving procedure performed when the heart stops beating. Place the patient face up on a firm, flat surface to maximize the effectiveness of chest compressions.

à Remove clothes to expose the chest.

à Place heel of one hand in the center of the chest on the breastbone. Place the heel of the other hand directly on the top of the first. Interlace the fingers. Position the shoulder directly over the hands. Keep the elbow straight and push straight down.

à Compress the chest hard and fast at least 5cm at a rate of 100- 120/min

à For infant place two fingers in the center of the chest, just below the nipple line, on the lower half of the sternum. Or place both thumbs side by side in the center of the infant’s chest, on the lower half of the sternum. Encircle the infant’s chest and support the infant’s back with the fingers of both hands. Compress approximately 4cm of the infant’s chest

à For very small child 1-handed compression to achieve the desired compression depth. Compress the depth about 5cm depth.

HOW TO USE POCKET MASK/ BAG AND MASK

à 2 breaths should be provided after each set of 30 compressions. Pocket mask, bag and mask ventilation can be used.

à Seal the pocket mask firmly against the patient face after using head tilt chin lift to open the patient’s airway.

à The tip of the mask should be at the bridge of the nose and the mask should cover the face till the chin.

à Make a good seal between the mask and the face with both hands and deliver each breath over one second. Each breath should be delivered for 1 second and should achieve a visible chest rise.

à When using the bag and mask device the rescuer gets into position at the patient’s head and circles the thumb and first finger around the top of the mask (forming a “c”) while using the third, fourth and fifth fingers (forming an “E”) to lift the jaw. This is called E-C clamp technique.

POINTS TO BE NOTED

· Allow the chest to completely recoil after each compression.

· Avoid lifting the hand completely off the chest.

· Switch compressors about every 2 minutes or earlier if fatigued. The switch should only take about 5 seconds.

· Minimize interruptions in compressions to 10 seconds or less as it reduced the blood flow to the brain.

· Avoid excessive and prolonged ventilation.

· Avoid inappropriate pulse checks.

· Avoid unnecessary movement of the patient.

· Continue to perform CPR until code blue team arrives.

· If there is 2 rescuer the compression: breath rate for an infant will be 15:2.

AUTOMATED EXTERNAL DEFIBRILLATOR (AED) / MANUAL DEFIBRILLATOR

à Automated external defibrillator is a light weight portable device that can identify abnormal heart rhythms that needs shock.

à AED can deliver a shock and convert abnormal rhythms back to normal.

à AED uses voice probes, lights and onscreen messages to guide the rescuer.

à Place AED pad or defibrillator paddles just below the clavicle on the right side and the second pad 6-8cm below the left armpit.

à Remove the paddle forcibly to rip off the excess hair on the chest, if present. Apply the second set of paddles.

à Connect the pad the AED machine and follow the instruction of the machine itself.

à A cardiac monitor with defibrillation capability can be used administering a transthoracic electrical current to a person experiencing one of the two lethal ventricular dysrhythmias, ventricular fibrillation (VT) or pulseless ventricular tachycardia pVT.

à Place the defibrillator in the defibrillation mode and the defibrillator’s capacitor is charged.

à On biphasic defibrillator initial energy is between 120-200 joules. On monophasic, it is 360 joules.

à Once fully charged, the scene is checked to make sure that no one is touching the patient or in contact with anything that is touching the patient. Discontinue oxygen supply other than the closed system (ventilator).

à The shock button is then pressed, allowing the stored charge to be delivered across the chest from paddle to paddle or hands-free pad to pad.

Continue high quality CPR until the code blue team arrives or person regains consciousness.

NM1701b - ALS

PRIMARY ASSESSMENT

A. Airway

B. Breathing

C. Circulation

D. Disability

E. Exposure

A. AIRWAY MANAGEMENT

Airway

Loss of tone in the throat muscle causes the patient’s tongue to fall back. It obstructs airway at the pharynx.

Assessment

· Listening to the person’s breathing, looking at the person’s chest and neck movements.

· Assess the external features like morbid obesity, buck teeth.

· Evaluate the 3-3-2 (3 fingers I mouth, 3 fingers fit from mentum to hyoid cartilage, 2 fingers fit from floor of the mouth to the top of thyroid cartilage.

· Assess for mallampati classification.

· Check for obstruction foreign body, mass, hematoma

· Check for Neck mobility (trauma, elderly)

The interventions to open the airway are

§ Airway maneuvers

§ Airway adjuncts

§ Suctioning the airway

§ Advanced airway devices

§ Airway maneuver

Head-tilt Chin Lift Maneuver

It relieve the airway obstruction by the tongue or from relaxed upper airway muscles.

Place one hand on the victim’s forehead and apply firm, backward pressure with palm, tilting the head back. Place the fingers of the other hand under the bony part of the lower jaw near the chin. Lift the jaw upward to bring the chin forward and the teeth almost to occlusion.

Do not press deeply into the soft tissue under the chin, because this might obstruct the airway. Do not use the thumb to lift the chin.

Jaw-Thrust Maneuver

It is used in trauma patient with suspected neck injury. Place one hand on each side of the victim’s head, resting your elbows on the surface on which the victim is lying. Grasp the angles of victim’s lower jaw and lift with both hands. If the lips close, retract the lower jaw with the thumb.

For unconscious patient with no gag reflex or cough, oropharyngeal airway or nasopharyngeal airway helps to maintain an open airway.

For a choking patient in respiratory arrest, look for a foreign object. When you open the mouth to give breath if you see one remove it, if you do not see a foreign body object start CPR. Each time you open the airway to give breaths, open the mouth wide, and look for and remove any foreign object.

§ Airway adjuncts

OPA (Oropharyngeal airway)

The OPA is a J shaped device that fits over the tongue to hold both it and the soft hypo pharyngeal structures away from the posterior wall of the pharynx.

Uses

· Patients at risk of developing airway obstruction from the tongue or from relaxed upper airway muscles.

· Unconscious patients when other procedures fail to maintain a clear, unobstructed airway.

· Facilitating suctioning of intubated patient’s mouths and throats.

· Preventing patients from biting and obstructing the ET tube.

Technique

· Clear the mouth and pharynx of secretions, blood, or vomit by using a rigid pharyngeal suction tip if possible.

· Select the proper size OPA, and place it against the side of the face. When the flange of the OPA at the corner of the mouth, the tip is at the angle of the mandible.

· Insert the OPA so that it curves upward toward the hard palate as it enters the mouth.

· As the OPA passes through the oral cavity and approaches the posterior wall of the pharynx, rotate the device 180⁰ into the proper position. Or insert the OPA at a 90⁰ angle to the mouth and then turn it down toward the posterior pharynx as you advance it.

Caution

· OPA that are too large may obstruct the larynx or cause trauma to the laryngeal structures.

· OPA that are too small or inserted improperly may push the base of the tongue back and obstruct the airway.

· Insert the OPA carefully to avoid soft tissue trauma to the lips and tongue.

· Remember to use the OPA only in the unresponsive patient with no cough or gag reflex. If the patient has a cough or gag reflex, the OPA may stimulate vomiting and laryngospasm.

NPA (nasopharyngeal airway)

The NPA is a soft rubber or plastic uncuffed tube that provides a conduit for airflow between the nostrils and the pharynx.

NPA may be used in conscious, semiconscious, or unconscious patients (patients with intact cough and gag reflex).

Technique

1. Select the proper size NPA

a. Compare the outer circumference of the NPA with the inner opening of the nostrils. The NPA should not be so large that it causes sustained blanching of the nostrils. The diameter of the patient’s smallest finger can be used as a guide for the proper size.

b. The NPA should be as long as the distance from the tip of the patient’s nose to the earlobe.

2. Lubricate the airway with a water-soluble lubricant or anesthetic jelly.

3. Insert the airway through the nostril in a posterior direction perpendicular to the plane of face. Pass it gently along the floor of the nasopharynx. If there is resistance,

• Slightly rotate the NPA to insert at the angle of the nasal passage and nasopharynx.

• Attempt to place through the other nostril.

4. Re-evaluate often, and maintain head tilt by using a chin lift or jaw thrust. Mucus, blood, vomit, or the soft tissues of the pharynx can obstruct the NPA, which has a small internal diameter. Frequently evaluate, and suction the airway if needed to ensure patency.

Caution

· Insert the airway gently to avoid complications. The airway can irritate the mucosa or lacerate adenoidal tissue and cause bleeding, and the patient could aspirate blood clots.do suction to remove blood or secretions.

· An improperly sized NPA may enter the esophagus. With active ventilation, such as bag-mask ventilation, an NPA in the esophagus may cause gastric inflation and possible hypoventilation.

· An NPA may cause laryngospasm and vomiting, even though it is commonly tolerated by semiconscious patient.

· Use caution in patients with facial trauma because of the risk of misplacement into the cranial cavity through a fractured cribriform plate.

Suctioning

Suction devices include portable and wall-mounted units.

Portable suction devices are easy to transport but may not provide adequate suction power.

Wall mounted suction units should be able to provide an airflow of more than 40L/min at the end of the delivery tube and vacuum of more than - 300mm Hg when the tube is clamped at full section.

Suction the airway immediately if the patient has copious secretions, blood or vomit.

Soft flexible catheters

· In the mouth or nose

· For ET tube deep suctioning

· For aspiration of thin secretions from the oropharynx and nasopharynx.

· To perform the intracranial suctioning.

· To suction through an in-place airway (NPA) to access the back of the pharynx in a patient with clenched teeth.

Rigid catheters

· To suction the oropharynx

· For suctioning thick secretions and particulate matter

· For more effective suctioning of the pharynx.

Oropharyngeal Suctioning Procedure

· Measure the catheter before suctioning.

· Gently insert the suction catheter or device into the oropharynx beyond the tongue.do not insert it any further than the distance from the tip of the nose to the earlobe.

· Apply suction by occluding the side opening of the catheter while withdrawing with a rotating or twisting motion.

· If using a rigid suction device, place the tip gently into the oral cavity. Advance by pushing the tongue down to reach the oropharynx if necessary.

· Limit each suction attempt to 10 seconds or less.

Advanced airway devices

v Laryngeal Mask Airway

· ET Tube (Refer NM1301)

· Cricothyroidotomy

· Tracheostomy tube (Refer NM1303)

Laryngeal mask airway

· Laryngeal mask airway is based on a close imitation of the swallowing mechanism. Before attempting insertion, the LMA cuff should be completely deflated and lubricated. The LMA is held with the dominant hand. The hand holds the LMA like a pen, with the index finger placed at the junction of the cuff and the shaft, with the LMA opening oriented over the tongue. The LMA is passed behind the upper incisors, with the shaft parallel to the patient’s chest and the index finger pointing toward the intubator. The lubricated LMA is pushed into position along the palatopharyngeal curve, with the index finger is used to push the LMA in the final position.

Cricothyrotomy

· Cricothyrotomy is performed by inserting a tube through an incision in the cricothyroid membrane.

B. BREATHING

Monitor the adequacy of ventilation and oxygenation

· Clinical criteria (chest rise and cyanosis)

· Pulse oximetry - Peripheral oxygen saturation (Spo2) can be monitored noninvasively through pulse oximetry. Normal pulse oximetry reading should be between 95 - 98%.

· Quantitative waveform capnography.

• End tidal carbon dioxide (ETCO₂) is the level of carbon dioxide that is released at the end of an exhaled breath. In a side stream configuration, the CO₂sensor is located in the monitoring device, which is at a distance from the patient. The exhaled CO₂is diverted from the airway into the device via a sampling tube of six to eight feet in length, which is attached to the breathing circuit fitted to the patient.

• In main stream configuration, the CO₂sensor and a sampling cell are integrated into a small device that connects directly at airway, between the breathing circuit and endotracheal tube.

Give supplemental oxygen

Adjust the supplemental oxygen to maintain 95 - 98% saturation.

100% - Respiratory or cardiac arrest

90% - Acute coronary syndrome if patient is not in respiratory distress

92% - 98% - Post cardiac arrest care

C. CIRCULATION

· Monitor CPR quality.

à Feedback devices

à Quantitative waveform capnography

An ETCO2 less than 10 mmHg during chest compressions rarely results in ROSC. A sudden increase in ETCO2 to more than 25 mm Hg may indicate ROSC.

à Intra-arterial pressure monitoring

The most common way of arterial pressure monitoring via the cannulation of a peripheral artery. Each cardiac contraction exerts pressure, which results in mechanical motion of flow within the catheter. The mechanical motion is transmitted to a transducer via a rigid fluid filled tubing. The transducer converts this information into electrical signals, which are transmitted to the monitor. The monitor displays a beat to beat arterial waveform.

Diastolic pressure corresponds to the arterial pressure during the cardiac relaxation phase. If relaxation phase is less than 20 mm Hg, attempt to improve CPR quality.

· Attach defibrillator for arrhythmias or cardiac arrest rhythms (VF, pVT,) and provide defibrillation or cardioversion.

· Obtain IV/IO access and give IV fluids if needed.

· Give appropriate drugs to manage rhythm and blood pressure

Inj.Epinephrine 1mg (IM/IV) every 3-5 minutes in both shockable and non-shockable rhythm.

Consider appropriate antiarrhythmic.

· Check glucose and temperature.

· Check perfusion status.

Perfusion status is determined by a combination of parameters that include heart rate, blood pressure, tissue color and mental status.

a) Adult systolic pressure less than 90mmHg, pediatric systolic blood pressure less than 70mmHg

b) Bradycardia, tachycardia and/or poor pulse quality (weak/thread)

c) Altered mental status (anxiety, restlessness, lethargy)

d) Delayed capillary refill time (greater than 2 seconds) and/or changes in tissue color including pallor, cyanosis or mottling.

D. DISABILITY

1. Check for neurologic function.

2. Quickly assess for responsiveness, level of consciousness and pupil dilation.

3. AVPU Scale

· Alert: the patient is aware of the examiner and can respond to the environment around them independently. The patient can also follow commands, open their eyes spontaneously, and track objects.

· Verbally responsive: the patient’s eye do not open spontaneously. The patient’s eye open only in response to a verbal stimulus directed toward them. The patient can react to that verbal stimulus directly and in a meaningful way.

· Painfully responsive: the patient’s eye do not open spontaneously. The patient will only respond to the application of painful stimuli by an examiner. The patient may move, moan, or cry out directly in response to the painful stimuli.

· Unresponsive: the patient does not respond spontaneously. The patient does not respond to verbal or painful stimuli.

E. EXPOSURE

· Remove clothing to perform a physical examination.

· Look for obvious signs of trauma, bleeding, burns, unusual markings, or medical alert bracelets.

SECONDARY ASSESSMENT

The secondary assessment involves the differential diagnosis, including a focused medical history and searching for and treating underlying causes. (H’s and T’s).

SAMPLE (memory aid)

• Signs and symptoms

• Allergies

• Past medical history (especially relating to the current illness)

• Last meal consumed

• Events

· Signs and symptoms

Breathing difficulty

Tachypnea, tachycardia

Fever, headache

Abdominal pain

Bleeding

· Allergies

Medications, foods, latex, etc.

Associated reactions.

· Medications (including the last dose taken)

Patient medications, including over-the-counter, vitamins, inhalers and herbal supplements.

Last dose and time of recent medications.

Medications that can be found in the patient’s home

Past surgical history (especially relating to the current illness)

Health history (e.g. previous illness, hospitalizations)

Family health history (in cases of ACS or stroke)

Significant underlying medical problems

Past surgeries

Immunization status

· Last meal consumed

Time and nature of last intake of liquid or food

· Events

Events leading to current illness or injury (e.g. onset sudden or gradual, type of injury)

Hazards at scene

Treatment during interval from onset of disease or injury until evaluation

Estimated time of onset (if out-of-hospital onset).

The answers to these questions help to quickly identify likely or suspected diagnoses.

• H’s and T’s (memory aid)

• Hypovolemia

• Hypoxia

• Hydrogen ion (acidosis)

• Hypo-/hyperkalemia

• Hypothermia

• Tension pneumothorax

• Tamponade

• Toxins

• Thrombosis (pulmonary)

• Thrombosis (coronary)

Hypovolemia

· It is a common cause of pulseless electrical activity (PEA)

· Rapid narrow –complex tachycardia and typically increases diastolic and decreases systolic pressures.

· Rapid correction of hypovolemia is the management

· The causes may hemorrhage, occult internal hemorrhage and dehydration.

Cardiac and pulmonary conditions

· ACS that involves a large amount of heart muscle can present as PEA, VF, pVT, or asystole.

· Occlusion of the left main or proximal left anterior descending coronary artery can present with cardiogenic shock rapidly progressing to cardiac arrest and PEA.

· Massive or saddle pulmonary embolism obstruct the pulmonary vasculature and causes acute right heart failure and fibrinolytic administration required.

· Pericardial tamponade may be reversible with pericardiocentesis, and during periarrest, volume infusion is recommended.

· Certain drug overdose and toxic exposures may lead to peripheral vascular dilatation and/or myocardial dysfunction with resultant hypotension and cardiovascular collapse.

· Tension pneumothorax can be treated with needle compression and chest tube insertion.

NM1703a - NEONATAL RESUSCITATION

DEFINITION

Measures taken to revive newborns who have difficulty in establishing respiration at birth and includes suctioning , positive pressure ventilation, external cardiac massage, intubation and medications as necessitated by the neonate’s condition at one minute after birth.

PURPOSES

To establish and maintain a clear airway.

To ensure effective circulation

To correct any acidosis present.

To prevent hypothermia, hypoglycemia, and hemorrhage.

ARTICLES

1. Suctioning Article

· Bulb syringe

· De lee mucus trap with no.10 Fr catheter or mechanical action.

· Suction catheters no.6,8 10

· Feeding tube no.8 Fr and 20mL syringe.

2. Bag and Mask Articles

· Infant resuscitation bag with pressure release valve or pressure gauge with reservoir, capable of delivering 90-100% oxygen.

· Face masks with cushioned rims (newborns and premature sizes).

· Oral airways (newborns and premature sizes).

· Oxygen with flow meter and tubing.

3. Intubation Articles

· Laryngoscope with straight blades No. 0 (premature), No.”1” (newborn).

· Extra bulbs and batteries for laryngoscopes.

· Endotracheal tubes. Sizes -2.5, 3.0, 3.5 and 4.0mm internal diameter.

· Stylet.

· Straight scissors.

4. Medications

· Epinephrine 1:10,000 ampoules (1mL ampoule of 1: 1,000 available in India).

· Naloxone hydrochloride (neonatal narcan 0.02 mg/mL.

· Volume expander.

o Normal saline.

o Ringer’s lactate.

· Sodium bicarbonate 4.2% (1meq/2ml) 7.5% strength available in India is approximately 0.9mEq/mL.

· Dextrose 10% concentration 250ml

· Sterile water 30mL

· Normal saline 30mL.

4. MISCELLANEOUS:

· Radiant warmer.

· Stethoscope

· Adhesive tape and bandage straight scissors.

· Neonatal Resuscitation

· Syringe 1 ml, 2 ml, 5 ml, and 20ml sizes.

· Needles os.21, 22, and 26G.

· Umbilical cord clamp.

· Gloves

· Warm dry towels.

PROCEDURE

NURSING ACTION	RATIONALE
Assess the APGAR score. Assess whether baby is vigorous or not.	Helps to know if resuscitation measures are to be instituted. Vigorous baby Strong cry or good respiratory effort Good tone HR> 100/min.
Place infant under warmer, quickly dry off amniotic fluid, replace wet sheets with a dry one.	Prevents heat loss.
Place the baby on his back with slightly head down 15 degree tilt, neck slightly extended.	Straightens the trachea and opens the airway. Hyperextension may cause airway obstruction.
Suction the mouth first and then nose.	Clears the airway passage. Infants often gasps when the nose is suctioned and may aspirate secretion from the mouth into lungs.
	Tactile stimulation may bring spontaneous respiration.
Give tactile stimulation if infant does not breathe (flick or tap the sole of foot twice or rub the back). Do not slap.
Check the vital signs and color of the newborn.	Helps in determining further need for resuscitation.

NOTES

Evaluation should be done on respiration, heart rate and color. If the baby is apneic, heart rate is less than 100 bpm and poor tone is present, proceed for bag and mask ventilation or positive pressure ventilation.

BAG AND MASK VENTILATION/POSITIVE PRESSURE VENTILATION

INDICATION

Apnea, poor tone

Heart rate less than 100 bpm.

Neonatal Resuscitation

Persisting after suction, positioning and stimulation

PROCEDURE

NURSING ACTION	RATIONALE
Place the new born on his back with head slightly extended.	Helps in opening airway. Hyperextension may cause airway obstruction.
A tight seal is to be formed over the infant’s mouth and nose with the face mask.	Prevents leakage of oxygen from the sides of the mask
Ventilate at a rate of 40-50/minute.
Ventilate for 15-30 seconds and evaluate.	Spontaneous respiration may be initiated with initial attempts to ventilate.
Have an assistant to evaluate, listen to the heart rate for 6 seconds and multiply by 10.

EVALUATION

· If heart rate is above 100 bpm and spontaneous respirations are present, discontinue bagging.

· If heart rate is 60-100 bpm and increasing, continue ventilation, check whether chest is moving adequately.

· If heart rate is below 60 bpm, start chest compression.

· If heart rate is below 60 bpm, in addition to bagging and chest compressions, consider intubation and initiate medications.

· Signs of improvement:

o Increasing heart rate.

o Spontaneous respirations.

o Improving color.

· Continue to provide free flow oxygen by face mask after respirations are established. If the baby deteriorates, check the following:

o Placement of face mask for tight seal.

o Head position and presence of secretions.

o Presence of air in the stomach preventing chest expansion.

o Oxygen being delivered. (100% or not).

For bagging lasting for more than two minutes, insert an oro-gastric tube to vent the stomach.

CHEST COMPRESSION

DEFINITION

Chest compression consists of r hythmic compressions of the sternum that compresses the heart against the spine, increases the intra-thoracic pressure and circulates blood to the vital organs.

Chest compressions must always be accompanied by ventilation with 100% oxygen to assure that the circulating blood is well-oxygenated.

INDICATIONS

Heart rate less than 60 bpm after bagging with 100% oxygen for 15-30 seconds.

PROCEDURE

NURSING ACTION	RATIONALE
Compress the chest by placing the hands the hands around the newborn’s chest with the fingers under the back to provide support and the thumbs over the lower third of the sternum (just above the xiphoid process).	Correct hand position compression then heart and avoids injury to the liver, spleen, fracture of the ribs and pneumothorax.
OR Use two fingers of one hand to compress the chest and place the other hand under the back to provide support.
Compress the sternum to a depth of approximately one-third of the antero-posterior diameter of the chest and with sufficient force to cause a palpable pulse. The fingers should remain in contact with the chest between compressions.	The size of the newborn determines the depth of compressions to avoid injury.
Use three compressions followed by one ventilation for a combined rate of compressions and ventilations of 120 each minute. This provides 90 compressions and 30 ventilations each minute. Pause for a ½ second after every third compression for ventilation.	Simultaneous compression and ventilation may interfere with adequate ventilation. The short pause allows air to enter the lungs.
Check the heart rate after 60 seconds. If it is 60 bpm or more, discontinue chest compression until the heart Periodic evaluation is necessary to ensure that treatment is appropriate to the infant’s status.	Periodic evaluation is necessary to ensure that treatment is appropriate to the infant’s status.

Note

If cardiac compression fails, endotracheal intubation should be initiated.

ENDOTRACHEAL INTUBATION

Indication

o Heart rate below 60/min inspire of bagging and chest compression.

o Presence of meconium in the amniotic fluid.

PROCEDURE

NURSING ACTION	RATIONALE
Place infant with head slightly extended with a rolled towel under the shoulder	Position makes the airway open
Introduce laryngoscope over the baby’s tongue at the right corner of the mouth.
Advance 2-3cm while rotating it to midline, until the epiglottis is seen. Elevation of the epiglottis with the tip of the laryngoscope reveals the vocal cord.
Suction secretion if needed.	Clears the airway.
Pass the endotracheal tube a distance of 1.5- 2cm into the trachea, hold it firmly but gently in place and withdraw the laryngoscope slowly.	Ensures adequate air entry into both lungs.
Attach the endotracheal tube to the adapter on the bag.
Ventilate with oxygen by bag. An assistant should check for adequate ventilation of both lungs with stethoscope.

MEDICTIONS

Medications should be administered if despite adequate ventilation with 100% oxygen and chest compression the heart rate remains at <60 bpm.

RECORDING

Record the procedure in nurse’s record. Document the baby’s condition before and after procedure.

Chest compression: after every third chest compression, ventilation should be continued.

In one minute, 90 chest compressions and 30 PPVs should be carried out (3: Ratio).

Medications:

Epinephrine: 0.1-0.3 ml/kg in 1: 10,000 dilution is given IV when there is persistent bradycardia. Intratracheal administration can also be given. It may be repeated every 15 minutes.

Sodium bicarbonate to combat metabolic acidosis (Ph <7.2) IV (4ml /kg of 0.5 mEq /ml, 4.2% solution) is given.

Reversal of narcotic drug is needed when mother has been given morphine within three hours of delivery. Naloxone 100mg/kg is given to the baby by IV, IM or endotracheal.

Volume expansion is needed when blood pressure is low and tissue perfusion is poor. Whole blood 5% albumin or packed red blood cells (10ml/kg), normal saline (10ml/kg) IV is given.

Dopamine infusion may be given for hypotension. (PIPV- positive pressure ventilation).

NM1801a -PATIENT TRANSFER & MODE OF TRANSPORTATION

DEFINITION

Patient care transfer can be defined as moving a patient from one flat surface to another. Patient transfer must be based on the concept that focuses on maintaining continuity of care both during and after hospitalization.

PREPARATION BEFORE TRANSFER

§ Perform hand hygiene.

§ Check the patient’s for any additional precautions.

§ Confirm the patient’s identification

§ Ensure patient privacy

§ Assess ABCDs (airway, breathing, circulation, and disability)

o Airway: if airway compromise is possible, electively intubate the patient with an endotracheal tube. Some patients require nasogastric tube placement to prevent gastric content’s aspiration during the transfer, while other patients may require cervical spine stabilization.

o Breathing: Control ventilation with optimized arterial blood gas levels. Ensure adequate oxygenation at all times.

o Circulation: critically ill patients typically have two large-bore IV cannulas in place before transfer in the event of shock or bleeding.

o Disability: patients with altered mental status or head injury should have their Glasgow coma scale monitored before, during, and after the transfer.

§ Ensure that all tubes, attachments, monitors, attached machines, patient wristbands, and lines are placed properly.

§ Obtain necessary equipment (slider board, full-size sheet/reducing sheet).

Special considerations:

§ Care giver should avoid using their weight to lift patients. Instead, patients should use their strength during transfers when possible.

§ Care giver should stay close to the patients at all times during the transfer to keep the patient’s weight close to the care giver’s centre of gravity.

§ Be careful not to let patients wrap their arms around the care giver’s head. If there is a communication barrier, the best resource is demonstrating the transfer using another person. Afterward, the patient is given hand signals to start the transfer.

TRANSFER FROM BED TO STRETCHER

à Identify the number of staff required for the transfer.

à Explain what the patient can do to help the procedure (hands crossed over the chest, chin tucked, etc.) and obtain necessary supplies.

à Raise /lower the bed to a safe working height, lock the brakes, lower side rails, and position the patient closest to the side of the bed where the transfer will place.

à Place a sheet on top of the slider board; this is used to transfer the patient onto the stretcher and decrease friction.

à Roll the patient over to the side opposite to the stretcher and place the slider board underneath the patient, such that the board is between the patient and the bed.

à Roll the patient back into the supine position, make sure the patient is centred on the slider board and that the feet are in a straight position.

à Bring the stretcher to the side of the bed near the patient and position the stretcher slightly lower than the bed. Lock the brakes of the stretcher.

à Position the team such that the patient’s weight is distributed evenly.

à Two on the side of the stretcher, grasping the sheet placed over the slide board.

à The leader of the health care team will initiate the transfer, counting 1, 2, and 3.

à The care givers on the far side of the bed will push the patient.

à The two care givers on the side of the stretcher will shift their weight from front to back, bringing the patient with them by pulling the sheet.

à Continue to slide the patient until the patient is on the stretcher’s centre.

à Remove the slide board from underneath the patient by rolling the patient over to the side opposite the bed. Make sure the patient is comfortable and covered with sheets.

à Raise the side rails and adjust the stretcher height.

TRANSFER FROM STRETCHER TO BED

à Bed and stretcher brakes must lock.

à Bed and stretcher must be of equal height.

à Lower the side rails.

à Advice the patient to keep the arm slightly raised and braced, elbows flexed.

à Two care givers positioned on the far side of the bed.

à Grip handle on the slider. Grip should see the wrists neutral and palms either down or rotated slightly upward with elbow flexed.

à Push back down, do not sit down first and do not pull with arms; keep elbows flexed, arms slightly raised, braced throughout the move.

à Roll the patient over to the side opposite to the bed and place the slider board underneath the patient, such that the board is between the patient and the bed.

à Roll the patient back into the supine position, make sure the patient is centred on the slider board and that the feet are in a straight position.

à Continue to slide the patient until the patient is on the centre of the bed.

à Remove the slide board from underneath the patient by rolling the patient over to the side opposite the stretcher. Make sure the patient is comfortable and covered with sheets.

à A pillow can be tucked slightly under the shoulder and rolled up with the repositioning draw sheet to stabilize the head and neck.

à A pillow can be placed under the patient’s legs for support and/or stabilization.

à Raise the side rails.

TRANSFER FROM A WHEELCHAIR TO BED

à Bring the wheelchair beside the bed. Make sure the person’s strong side is beside the bed. Lock the brakes. Remove safety belts.

à Lower the side rails of the bed.

à Put both feet flat on the floor. Move footrest out of the way.

à Ask the person to move forward in the wheelchair. Make sure their toes are under their knees.

à Stand in front of the person. Ask them to sit tall, lean forward and push down on the wheelchair armrest as you help them to stand.

à Place your hands around their upper back. If they have a weak arm, place your arm around it, not under it. Do not pull on the weak arm.

à Help the person to move until their bottom is over the edge of the bed. Help them sit down. The person should:

a) Reach for the bed

b) Bend knees

c) Keep shoulders forward

à Raise the side rails.

TRANSFER FROM BED TO WHEELCHAIR

à If the patient can bear weight on both lower extremities and can take small steps, a one-person assist may be performed.

à Otherwise two-person transfer or a mechanical lift may be necessary to safely transfer the patient.

à Apply the patient’s footwear before ambulation.

à Raise /lower the bed to a safe working height, lower the side rails, place wheelchair next to the bed at a 45⁰ and ensure the brakes are applied. If one side of the patient is weaker, place the wheelchair on the healthier side.

à Sit patient on the side of the bed with the legs off of the bed and the feet securely on the floor. If necessary, attach a gait belt/walking belt around the patient waist.

à Place hands on the patient waist.

à The care givers positions his/her legs on the outside of the patient’s legs.as the patient lean forward, bending at the waist, the provide grasps the gait belt. ( or the patient waist)

à Place hands on the patient waist.

à Help the patient shift weight in a rocking motion (front to back, and so on) until reaching a standing position.

à Once the patient is standing, have them walk a few small steps backward until the feeling the wheelchair’s back against the legs.

à Ask the patient to grasp the wheelchair.

à The care givers will shift their weight from back to front as the patient sits in the wheelchair slowly, using the wheelchair’s arm for support.

à Ensure that the patient is adequately draped and sitting comfortably in the wheelchair.

à Patient may use slide boards for more effortless transfer.

à Assist the patient to wear safety belt.

LOG-ROLLING PROCEDURE

à The purpose of the log-rolling procedure is to move a patient without flexing the spinal column. The entire body is transferred as a single object.

à If a neck injury is a concern, a firm neck support should be in place, and in-line traction should be maintained with multiple assistants while performing the procedure.

à The patient should not ambulate until proper examination and radiographs are obtained.

à Keep the patient’s arms on the side of the body at all times. Some recommend that the patient’s arms be crossed over the chest.

à A pillow can be placed between the legs for support while turning.

POINTS TO REMEMBER

à While transferring the patient in stretcher the foot end must be preceded the head end while passing through the slope the same position will be maintained.

à Health care worker at the front side must stand on the side and pull the stretcher.

à Oxygen cylinders must be filled with at least 80%.

à Humidifier attached to the cylinder must be erect and preferably filled with Double distilled water.

à Urine bag and other attachment must be placed properly on the fixed areas.

à Other than medical record no other patient belongings should not be carried in the stretcher. Caution must be taken to avoid damage to medical record.

à IV fluids, blood and blood products must be clamped while transporting the patient.

à While transferring the patient in wheelchair the patient should precede the care givers. While passing through the slope the patient turns around and backside of the wheelchair should precede first.

NM1901a - SKIN TRACTION

DEFINITION

A nonsurgical procedure that makes use of adhesive straps, slings, and halters applied to skin for attachment of weight, to exert indirect pull or traction on underlying structure.

PURPOSE

• To immobilize a part requiring partial or temporary immobilization.

• To reduce fractures and dislocations in children.

• To reduce fractures in adults temporarily before definitive treatment is given.

• To correct flexion deformities of knee or hip.

ARTICLES

· Traction pulley bracket.

· Traction brace

· Spirit/iodine for skin preparation

· Dry gauze

· Roller bandages/ Traction rope

· Bed blocks and weights

· Adhesive plaster

· Straight scissors

· Kidney tray

GUIDELINES FOR USE OF TRACTION

• Maintain the established line of pull.

• Prevent friction.

• Maintain counter traction.

• Maintain continuous traction unless otherwise ordered.

• Maintain correct body alignment.

PROCEDURE

NURSING ACTION	RATIONALE
Assess patient’s overall health including degree of morbidity.	Determines patient’s health status and ability to tolerate
Assess condition of specific tissues to be placed in traction. Note the skin condition, excessive hair, bruises, and other lesions.
Assess patient’s understanding of reason for traction.	Determines concerns, acceptance and need for instruction.
Assess patient’s level of pain.	Serves as baseline for later comparison
Explain procedure to patient, including traction set-up and mobility restrictions.	Promotes cooperation and reduces anxiety.
Prepare patient as requested by physician	Position varies with part of body to be placed on traction, plus effects of weight and gravity.
Assist with application of specific head halter, adhesive strips and elastic bandages and pelvic belt or sling as needed. Nurse may be asked to hold patient in desired position or apply halter, strips or elastic bandages while physician and other assistants hold patient limb in desired position.	For lower extremity, adhesive strips are applied beginning below head of fibula on lateral surface of leg to avoid pressure over peroneal nerve .Ensure proper alignment of body parts under traction. Elastic bandages are applied from distal to proximal to promote venous return.
Assist with attachment of spreader bar, ropes and pulleys. Ropes are tied securely in knot and passed in grooves of pulleys to weights.	Provide proper weighted traction for extremity alignment.
When all traction materials and spreader bars are in place, weights are placed on weight holder and hooked to loop in rope till it is taut. Physician determines exact amount of weight to be applied and position to be maintained by patient.	Traction is slowly established to avoid involuntary muscle spasm or pain for patient. Weight should be sufficient to create enough pull to overcome muscle spasm, but not to cause distraction or marked increase in pain.
Before physician leaves check patient’s position and ask about additional permissible position for patient in bed.	Ensure safety of care and position for effective traction.
Ask patient how to traction is affecting injured tissues if patient is able to respond. Babies or young children may cry when weights are initially applied but may soon stop crying and appear more comfortable.	Initial reaction may be slight increase in soreness or pain until patient is able to relax and allow traction to perform as designed.
Place side rails elevated as appropriate.	Promotes patient safety.
Gather unused material and return to storage areas.
Wash hands	Reduces transmission of micro-organism.
Observe entire skin traction set up and its functioning, Check all knots, ropes in pulleys, weight on weight holder, whether apparatus is hanging freely, position of halter sling, belt or other material for specific traction.	Reassessment is necessary to determine if traction is functioning as designed or described or to make needed adjustments.
Assess condition of skin around straps or bandages.	Ensures early identification of irritation or breakdown.
Ask if patient experiencing pain or burning sensation.	Indicates misalignment of bones or presence of muscles spasm.
Conduct neuromuscular checks every 1-2 hours initially, then every 4 hours if patient is stabilizing.	Provides objective data concerning peripheral perfusion to tissues.
Observe patient participation in self-care	Patient may refrain from actively unnecessarily.
Record type of traction, site to which applied, amount of weight, time, patient's response and other relevant information in the medical record.	Ensures continuity of care and provides documentation for legal considerations.
Record traction functioning every shift. Observe all ropes, pulleys, weights and strings at the beginning of shift and after turning or position changes or if traction is removed for providing nursing care.	Safety, continuity of care and legal factors recording of all details.

CARE OF SKIN TRACTION

ASSESSMENT

¨ Assess for pain, deformity, swelling, motor and sensory function and circulatory status of the affected extremity.

¨ Assess the skin condition of the affected extremity, under skin traction and around skeletal traction, as well as over bony prominences throughout the body.

¨ Assess for the alignment of the affected body part.

¨ Assess for signs and symptoms of complication

¨ Assess traction equipment for safety and effectiveness.

a. The patient is placed in a firm mattress.

b. The ropes and pulleys should be in alignment.

c. The pull should be in line with the long axis of the bone.

d. Any factor that might reduce the pull or alter its direction must be eliminated.

i. Weights should be hanging freely.

ii. Ropes should be unobstructed and not in contact with the bed of equipment.

e. The amount of weight applied in skin traction must not exceed the tolerance of the skin. The condition of the skin must be inspected frequently.

f. Cover exposed sharp end of skeletal pins with cork or other pin covering to protect patient and caregivers from injury.

¨ Assess emotional reaction to condition and traction.

¨ Assess understanding of treatment plan.

NURSING INTERVENTIONS

Minimizing the effect of immobility

a. With running traction, the patient may not be turned without disrupting the line of pull.

b. With balanced suspension traction, the patient may be elevated ,turning slightly, and moved as desired

Maintain skin integrity

· Examine bony prominences frequently for evidence of pressure or friction irritation.

· Observe for skin irritation around the traction bandages.

· Observe for pressure at traction-skin contact points.

· Report complaint of burning sensation under traction.

· Relieve pressure without disrupting traction effectiveness.

a. Make sure that linen and clothing are wrinkle free.

b. Use pressure injury prevention devices and special mattresses as needed.

· Special care must be given to the back every two hours because the patient maintains a supine positions.

a. Provide back massage.

Preventing neurovascular injury

v Assess motor and sensory function of specific nerves that might be compromised.

a. Peroneal nerve-have patient point great toe toward nose; check sensation on dorsum of foot; presence of foot drop.

b. Radial nerve-have patient extend thumb; check sensation in web between thumb and index finger.

c. Median nerve- thumb-middle finger apposition. Check sensation of index finger.

v Determine adequately of circulation (e.g. Color, temperature, motion, capillary filling of peripheral fingers too.

a. With a buck’s traction, inspect the foot for circulatory difficulties within a few minutes and then periodically after the elastic bandages has been applied.

b. Report promptly if change in neurovascular status is identified.

SKELTAL TRACTION

DEFINITION

Skeletal traction is applied to the bone and requires a surgical procedure in which pins or wires are inserted into the bone for attachment of weight.

PURPOSE

ARTICLE

· Towels and towel clips

· Dressing cups-2

· Dressing material

· No.11 scalpel and blade

· 5ml syringe

· Needle 20G,22G

· Local anesthetic

· 2 Pair Of Sterile Gloves

· Kirschner Wire/ Steinmann Pin/ Denham Pin

· T Handle, Drill Bit, Hand Drill

· Stirrup

· Traction Ropes, Out Rigger, Sandbags

PROCEDURE

Explain the need for skeletal traction and the method of application.

Emphasize the importance of maintaining counter-balance, alignment and position.

Explain about the pain relief interventions provided during and after the procedure.

NURSING ACTION	RATIONALE
Provide privacy	Ensures respect for patient dignity
Assess the skin at the proposed pin insertion sites for inflammation and infection, check the distal pulse.	Infections at the site of pin insertion predisposes to osteomyelitis; checking pulse gives baseline data.
Assist the surgeon in preparing skin and administering local anesthesia.	Local anesthesia provides analgesia during the procedure.
Open the sterile supplies using aseptic technique. Wear gloves and assist the surgeon in inserting the pin/wire. Attach the stirrup to the pin/ wire. Assist the surgeon in covering the pin site with iodine soaked gauze.	Aseptic technique ensures prevention of spread microorganism. Proper traction application reduces the risk of injury by promoting accurate counterbalance and function of traction.
Transfer the patient to the bed
Observe for any complications e.g., pain, altered sensation and absence of distal pulse.	Neurovascular assessment aids in early identification and allows for prompt intervention
Place the traction rope over the pulley of the out trigger and connect sandbags of the required weight.
Ensure that the weights hang freely, ropes move freely through the pulley, all knots are tight and are positioned away from pulley.	Proper traction application reduces the risk of injury by promoting accurate counterbalance and function of the traction.
Perform skin assessment check pressure points, including ischial tuberosity, popliteal space, sacrum and heel.	Skin assessment provides early intervention for skin irritation, impaired tissue perfusion, and other complication.
Document the date and time of application, type and location of the traction, any special bed/frame used, amount of weights used, patient’s tolerance to procedure, anesthesia used, vital signs, and instructions given.	Documentation helps for referral and further plan of care.

COMPLICATION

Pressure injury

Venus stasis

Thrombophlebitis

Constipation

Loss of muscle strength

Atelectasis

Osteomyelitis

Neurovascular compromise.

CARE OF SKELTAL TRACTION

ASSESSMENT

· Determine the patient understands of procedure and fixation device.

· Evaluate neurovascular status of involved body part.

· Inspect each pin site for redness, drainage, tenderness, pain, and loosening of the pain.

· Inspect open wound for healing, infection or devitalized tissue.

· Assess functioning of other body systems affected by injury or immobilizations.

INTERVENTIONS

Relieving anxiety

· If possible, before placement of the device, reassure the patient that, although the fixator appears awkward and heavy it should not hurt once it is place.

· Emphasize the positive aspect of this device in treating complex musculoskeletal problem.

· Encourage the patient to verbalize reaction to the device.

· Inform the patient that greater mobility can be achieved with an external fixation device, thereby minimizing the development of other system problems.

· Involve the patient in care and in the management of external fixator.

Maintaining intact neurovascular status

· Assess neurovascular status frequently-every 15 minutes to 1 hour while swelling is significant and later, every 2 to 8 hours.

· Establish baseline of functioning for comparative monitoring. Complex musculoskeletal injuries frequently result in disruption of soft tissue functioning.

· Elevate extremity to reduce swelling.

· Report any change in neurovascular status.

Avoiding Infection at Pin Site

§ Monitor vital signs for fever or tachycardia

§ Watch for signs of infection, especially around the pin tract.

a. The pin should be immobile in the bone and the skin surrounding the wound should be dry. Small amount of serous oozing from pin site may occur.

b. If infection is suspected, percuss gently over the tibia; this may elicit pain if infection is developing.

c. Assess for other signs of infection; heat, redness, fever.

§ If directed, clean the pin tract with sterile application and prescribed solution or ointment (normal saline, sterile water, chlorhexidine) - to clear drainage at the entrance tract and around the pin because plugging at this site can predispose to bacterial invasion of the tract and bone.

Preventing infection.

a. Provide site and fixator care

b. Clean pin sites and remove crusts with sterile cotton applicator, using solution as prescribed, or established standard of care.

c. Crusts formed by serous drainage can prevent fluid from draining and can cause infection.

d. A small amount of serous drainage from the pin sites is normal.

e. Note and report inflammation, swelling, tenderness, and purulent drainage at pin site.

f. Note the pin site tension can cause discomfort.

g. Report loosened pins.

h. Clean fixator with clean cloth and water, as needed.

· Provide wound care

a. The open wounds at the fracture site are usually treated by daily dressing changes.

b. Use sterile technique.

c. Note wound appearance. Monitor healing.

d. Report signs of infection.

· Monitor for local and systemic indicators of infection.

Encouraging mobility

· Encourage the patients to participate in care activities.

· Assure the patient that pain associated with injury will diminish as tissue reactions to injury as manipulation resolve and healing progresses.

· Inform the patient that the external fixator maintains the fracture in a stable position and that the extremity can be moved. Adjustment of the fixator is done by the health care provider.

· To move the extremity, grasp the frame and assist the patient to move. Reassure the patient that the fixator can withstand normal movement.

· Teach quadriceps exercises and ROM exercises for joints; usually started on first postoperative day.

· Teach crutch walking when soft tissue swelling has diminished; encourage weight-bearing, as prescribed.

NM1902a - APPLICATION OF SPLINT

DEFINITION

Splint is a device used for support or immobilization of limb or of the spine. Splinting is the application an immobilizing device for supporting or securing specific part of the body.

PURPOSE

To support body parts.

To correct or prevent deformity.

To provide stabilization.

To enable application of traction.

To provide an erect posture for weight bearing.

To manage sprains and strains.

ARTICLES

Appropriate type of splint.

Cotton pads.

Gauze bandages.

Adhesive tape

Straight scissors.

Gloves.

PROCEDURE

NURSING ACTION	RATIONALE
Explain procedure to patient.	Helps in obtaining cooperation of the patient.
Collect articles at bedside	Saves time and energy
Provide privacy and position body parts in its functional position.	Promotes comfort and good body mechanics.
Wash hands and don gloves	Prevents the spread of microorganisms
Position the patient comfortably and place the limb in its functional position.
Clean the area with soap and water then pat dry.	Open wounds can harbor microorganisms and reduce the effect of the medication applied
Check the distal pulse on the affected side.	Gives a baseline data and detects the vascular compromise.
Ensure that the splint is adequately padded. Pad the bony prominences and the space between skin surfaces. Keep the skin clean and dry.	Prevents skin breakdown from the irritation caused by the splints and infection.
Assist in application of splint and secure the splint with bandages	Promotes comfort and support.
Secure the edges of the bandage with adhesive tape. If straps of the splint are present, ensure that straps are put away from the injured area.
Check the distal pulse for any variation using the 6“P”s :pain, pallor,parasthesia,poikilothermia ,pulselessness , and paralysis.	Ensure early identification of circulatory and neurovascular compromise.
Elevate the splinted extremity unless it is contra-indicated. Apply ice if there is increased swelling.	Reduce swelling and pain.
Replacing articles and equipment.
Document date and time of splinting, the area splinted, type of splint, purpose of splint, patient’s response to the procedure, specific nursing interventions done, if any, to relieve discomfort and promote skin care and instructions given.

POST-PROCEDURE CARE

Place patient in a comfortable position.

Observe for any complications.

Check neurovascular status.

COMPLICATIONS

Pressure sores

Contractures

Venous stasis

SPECIAL INSTRUCTION

Inform about any discomfort or signs of neurovascular compromise.

Teach about skin care at home -remove the splint, clean the skin with soap and water, dry thoroughly, inspect the skin for ulcers and change of color and reapply the splint.

Teach the patient about splint care when dirty, remove the splint, clean with warm water, dry it under sun thoroughly and reapply.

Encourage range of motion exercises for all the uninfected joints, unless contra-indicated.

APPROPRIATE SPLINTS FOR VARIOUS INJURIES

INJURED PART	APPROPRIATE SPLINT
Cervical Spine	Hard Cervical Collar
Clavicle	Clavicular Brace with Broad Arm Sling
Scapula	Broad Arm Sling/ Triangular Sling
Humerus-Neck And Upper Third	Broad Arm Sling Or Triangular Sling
Humerus-Mid Or Lower Shaft	U-Slab
Supracondylar Fracture	Above Elbow Posterior Slab With Elbow At 110⁰
Forearm	Below Elbow Posterior Slab
Wrist	Below Elbow Volar Slab
Hand	Below Elbow Volar Slab In Functional Position
Radial nerve injury	Cock up splint.
Phalanges	Buddy Taping,aluminium splint.
Spine	Absolute Bed Rest
Pelvic Fracture	Bed Rest
Femur	Thomas Splint
Leg	Above Knee Posterior Slab
Ankle	Below Knee Posterior Slab

CARE OF SPLINT

Right after getting a cast

· It will feel warm and damp. It will take a few hours for it to harden and become cool.

· The toes and fingers on the injured limb may be a little blue or pale. Their color should go back to normal within 10 to 15 minutes.

For the first few days,

· The fingers or toes on the injured limb may be swollen.to reduce the swelling

o Apply cold packs directly over the injury and on the top of the cast or splint for 24 to 48 hours. Change the pack when it start to melt or when it’s no longer cool.

o For a non-waterproof cast or splint, protect it from getting wet by placing a cloth between the cast and the cold pack or putting the icepack in a plastic bag.

o Keep the hurt arm or leg raised above the level of the heart as much as possible. Like fingers must be higher than the elbow, toes should be higher than the level of nose.

· Do not put anything over the cast or splint until it is completely dry.

· Do not use paint, oil-based materials, duct tape or stickers on the cast. These things will clog the pores of the cast and keep air from getting to the skin.

· Do not walk unnecessarily unless if asked so. Putting weight on the cast could damage it or harm the skin inside.

Circulation checks

Skin color

· The fingers or toes should not be pale or bluish.

· Instruct to check the capillary refill by pressing the nail bed until it turns white. The color should return within 3 to 4 seconds.

· The toes and fingers should feel warm.

Sensation –there should not be tingling, numbness, or feeling like the limb is asleep.

Movement – the fingers and toes should move freely.

Skin care

· Check the skin around all edges of the cast each day for red, dry, swollen, cracked, blistered, or bleeding areas.

· Do not use lotions, oils or powders on the skin near or inside the cast. Powders can form balls that could fall into the cast and cause skin problems. Lotions will make the skin too soft and make prone to break down.

· Check for signs of an infected sore or wound

o Pain

o Fever

o Fingers or toes change color

o Strong, bad smell from cast.

· Watch for signs of pressure injury like pain in the new spot under the cast or splint, numbness, tingling, burning, or stinging in a new place.

· Change positions every 2 to 3 hours.

· Place or put pillows, towels under or bedside the cast to hold it in position.

· Do not rub the splint against anything.

· If itching is present

· Blow air into the opening of the cast.

· Do not massage the skin. It can damage the skin.

· Do not stick anything inside the cast or splint. This may injure the skin and lead to infection. It could cause wrinkle or tear the lining of the cast.

· Do not pull out or tear the lining of the cast. Do not add more padding.

Bathing and cast care

Waterproof cast

Avoid bathing in really soapy water. Flush well with clean water to make sure the soap is all rinsed off. Soap left on the body can cause itching.

After bathing, hold the casted limb upright. It helps to let the water drain out and not pool in anyone place.

Body heat will dry any water left inside the cast.

Non-waterproof cast

Cover and seal the cast with a plastic bag when bathing or showering.

Only use water on a damp washcloth to clean the outside of the cast.

Removal of splint

Using a cast saw the cast is removed.

Care after the cast is off

· Wash the skin gently. It may take a few days for the skin to go back normal.

· Do not rub, scrub, scratch, pick, or peel the skin.

· Soak the arm or leg in warm water. Use mild soap and a soft cloth. Pat the skin dry and leave it open to the air.

NM1905a - ASSIST IN CORRECTION OF DISLOCATIONS

Dislocation is a separation of both articulating surfaces of joint. Subluxation is a partial or incomplete displacement of the joint surface.

TYPES OF DISLOCATIONS

• Congenital dislocations

• Traumatic dislocations

• Pathologic dislocations

CAUSE

• Sports

• Motor vehicle accident

• Fall

• People are born with loose ligaments

CLINICAL MANIFESTATION

• Alter the length of affected extremity.

• Pain, even at slightest movement.

• Swelling and significant hemorrhage.

• Numbness

• Limited movements

• Change in the axis of dislocated bones

• Visible deformity

PROCEDURE

NURSING ACTION	RATIONALE
Check the doctor’s order.
Immobilize the joint while transporting the patient.
Perform hand hygiene.
Provide comfort devices to support the affected joint.
Elevate the dislocated joint.
Apply ice pack to the area.
Administer prescribed analgesics.
Arrange the articles near the patient side.
Positon the patient as per the maneuver.
Do not attempt to relocate.
Assist the physician throughout the procedure.
Instruct the patient regarding the management of immobilizing devices.
Observe for marked reduction and increased range of motion. Also check for palpable or audible relocation if possible.	It indicates successful reduction of the dislocated joint.
Observe for symptoms of neurological damage before and after the procedure.
Continuously observe patient breathing pattern.
Instruct the patient to wear the splint or traction till the prescribed time.
Discard the waste as per JMMCRI policy
Perform hand hygiene.
Document all relevant information in the medical record.

Notes

1. Kocher’s method

Bend the arm at the elbow, press it against the body, and rotate outwards until resistance is felt. Lift the externally rotated upper part of the arm in the sagittal plane as far as possible forwards and finally turn inwards slowly.

2. Stimson technique

The patient lie prone on the bed with dislocated arm hanging over the side. Traction is provided by upto5-15kg of weight attached to the wrist or above the elbow. Apply gentle internal/external humoral rotation. Reduction may take 20-30 minutes.

3. External rotation method

While the patient is supine, adduct the arm and flex it 90⁰ at the elbow. Slowly rotate the arm externally, pausing for pain. Reduce the shoulder before reaching the coronal plane. Reduction usually occurs with the arm externally rotated between 70 to 110 degrees.

4. Traction –counter traction

While the patient lies supine, apply axial traction to the arm with a sheet wrapped around the forearm and the elbow bent at 90⁰. An assistant should apply counter traction using a sheet wrapped under the arm and across the chest while the shoulder is gently rotated internally and externally to disengage the humeral head from the glenoid.

5. Scapular rotation

With the patient lying prone, apply manual traction or 5-15lb of hanging weight to the wrist. After relaxation, rotate the inferior tip of the scapula medially and the superior aspect laterally. Alternatively the patient can be seated while an assistant provides traction-counter traction by pulling on the wrist with one hand and bracing the upper chest with the other.

NM2001a - MANAGEMENT OF LABOUR

DEFINITION

Systematic process of enabling a woman to safely deliver fetus, placenta and membrane through birth canal.

PRINCIPLES

A safe environment is provided.

Asepsis is maintained throughout the procedure.

Injury to mother and fetus is prevented.

Deviation from normal is identified and prompt action is taken.

The mother is supported physically and psychologically.

PURPOSE

To help her deliver baby in a safe environment.

Detect and prevent complication during delivery.

EQUIPMENT

Delivery tray

Small cord cutting straight scissors and sterile pad-1

Bowl small with gauze

Needle holder

Episiotomy scissor

Suture cutting scissor

Suture material

Thumb forceps

Artery forceps straight

Delivery mat with drape

Sterile towels

Vaginal packing (if needed)

Surgical mop

PPE( apron, mask, gloves)

10cc syringe

18G needles

Vacutainer : EDTA bottle, heparin bottle – 2( for Rh negative mother)

Local anesthetic 2%

Xylocaine jelly (PV examination )

Nelcath (if needed)

Antiseptic solution

Plastic basin

BMW liners

PROCEDURE

NURSING ACTION	RATIONALE
Explain to the woman and offer encouragement all through delivery process.	Ensures the woman’s cooperation and comfort.
Provide privacy and position her comfortably (dorsal recumbent position).	For performing the procedure efficiently.
Assess the working status of the equipment at Newborn area, arrange all article for baby care near the baby cot.	Ensures an effective procedure and to prevents and manages any complication.
Wear personal protective equipment and scrub hands for 5 minutes. Wear sterile gloves.	Prevents cross infection.
Drape the woman with delivery sheet placing it under buttocks, leggings for legs and towel over abdomen.	Prevents cross infection and contamination.
Clean perineum with antiseptic lotion.	Prevents infection.
Ensure that the bladder is empty.	Prevents hypotonic uterine action, injury to bladder, promotes the descent of fetus and prevents postpartum hemorrhage.
Encourage her to bear down when she gets expulsive contractions.	Speeds up delivery following the natural urge of woman to push.
If episiotomy is necessary, do so when head crowns, after infiltrating perineum with local anesthetic.	Expedites delivery.
Infiltrate the perineum using 10ml of local anesthetic wait for 3-5 minutes for the anesthetic to act.	Minimizes pain during incision.
Place your index and middle fingers in the vagina with palmar side down and facing you. Separate them slightly and exert outward pressure on the perineal body.	Provides protection to the presenting part in two ways. a. The fingers are against the presenting part and are thick enough so that the straight scissors, if properly placed will not hurt the baby. b. The outward pressure directs the perineal body away from the baby. The pressure also flattens the perineal body a bit more, making it easier to incise using a single cut.
Place the blades of the straight scissors in a straight up and down position, so that one blade is against the posterior vaginal wall and the other blade is against the skin of the perineal body with the point where the blades cross at the middle of the posterior couchette
Adjust the length of the blades of the straight scissors on the perineal body and predict the length of the incision accordingly.	The length of the incision should be adequate to deliver the fetal head.
Support perineum with dominant hand using towel and control extension with non-dominant hand when head is being delivered.	Prevent injury to perineum due to sudden expulsion of fetal head.
Wait for restitution and external rotation of head which corresponds to untwisting of neck and internal rotation of shoulders to take place.	Allows the fetus to be born through natural course of events in delivery.
Hook neck by applying two fingers over neck and two under the neck and deliver anterior shoulder by giving downward traction. Then deliver posterior shoulder by giving upward traction.	Perform the delivery of shoulders of fetus.
Deliver body by lateral flexion (towards women abdomen).
Hold baby’s head to the angle of 45⁰ with head in low position.	Prevents aspiration.
Note time of birth.	Informs the woman as to the time of delivery, which is an auspicious event.
Wipe the eyes with sterile cotton	Prevents infection.
Cover cord with gauze piece and cut the umbilical cord in between the two clamps. Collect cord blood (2ml) for Rh and grouping.	Identifies any deviation from normal.
Administer inj.oxytocin 10 units IM after the delivery of the baby.	Prevent hemorrhage.
Apply pressure with 4”x4” sponges and apply vaginal packing.	Controls any slight bleeding present.
After completion of delivery assist for suturing of episiotomy incision
Evaluate baby's condition at birth.	Separates mother and baby.
The identification tag on mother and baby.	Ensures the right baby belongs to the right mother.
Show the mother to the baby and ask her to identify and repeat the genders of the baby.	Ensures legal protection.
Show the baby to other significant relatives and ask them to identify and repeat the sex of the baby.	Ensures that the right baby belongs to the right mother.
Receive baby in sterile sheet, clear airway, wipe and wrap baby.	Facilitate breathing.
Wait for placenta to separate and confirm separation (20 minutes).	Allows the placenta to separate following the normal course of events.
Deliver placenta by Modified Brand Andrews (MBA) method using controlled cord traction. Clamp cord near vulva and hold clamp with two fingers of dominant hand. Keep non-dominant hand just above symphysis pubis and exert pressure over the fundus in an upward direction.
Deliver placenta giving downward and backward traction the placenta comes out hold it on the palm of the hand and rotate gently to deliver the membrane. Examine the placenta membrane, cotyledon.	Ensures the complete delivery of the placenta.
Massage the uterus and empty the blood clots.	Ensures the tonicity of the uterus suturing prevents complication.
Initiate breastfeeding after baby care (within 10-15 minutes of delivery).
Clean perineum, change linen and make mother comfortable.	Promotes pain relief, cleanliness, and comfort.
Provide warm drink to the mother.	Enhance comfort.
Examine placenta .measure cord length by hand span and check with inch tape later. Place the placenta in a plastic cover and weigh it. Dispose as per hospital policy.	Identifies any abnormalities and ensures proper disposal of placenta.
Change gloves.
Wipe the wound area with sterile antiseptic cotton swabs.	Prevents spread of microorganism
Focus light on the perineal area	Gives clear visualization of the perineum
Diagnose the degree of the perineal tear if any	Continuous bleeding may obscure the place of suturing.
Visualize the apex of the mucosa, start suturing little above the apex. Appose the vaginal tear by continuous suture using a round body needle.
Examine for paraurethral, perineal or vaginal tear.
If a midline episiotomy was cut, palpate for the external anal sphincter.
Clean the perineum and apply perineal pads
Straighten patient's legs and assist her to supine position with legs crossed.	Makes the patient comfortable and reduces the chance of bleeding.
Wash and dry the instruments used for episiotomy along with those used for conduct of delivery and suturing.
Document all details as per hospital policy.	Maintains record of events and for legal purpose.

Notes

POST-PROCEDURE CARE

· Check for any bleeding from inner areas or hematoma formation

· Check vital signs

· Check for any other tear or laceration

· Provide fluids orally and make sure that the mother voids within 2 hours.

COMPLICATIONS

· Hematoma

· Infection

· Wound dehiscence

· Perineal laceration

· Dyspareunia

· Scar endometriosis

SPECIAL CONSIDERATIONS

· A rectal examination is made when suturing is completed in order to ensure that no sutures have penetrated the rectal mucosa to prevent fistula formation.

· The thread should not be pulled too tightly. This prevent edema formation.

· Ensure that all the details are recorded in the partograph.

NM2003a - CARE OF EPISIOTMY

Articles

· Sterile gauze

· Sterile Artery Curved forceps

· Bowl small

· Antiseptic solution

· Sterile gloves

· Kidney tray

Procedure

NURSING ACTION	RATIONALE
Identify the patient by hospital number.
Explain the procedure to the patient.
Provide privacy.
Arrange articles near the patient.
Assist the patient to lie on dorsal recumbent position.	Ensure proper body mechnics for the staff to perform procedure.
Perform hand hygiene and wear sterile gloves.	Prevents transmission of micro-organisms.
Check for REEDA ( redness, edema, ecchymosis, discharge, approximation of sutures )	To monitor the healing progress of episiotomy wound.
Inspect for type of lochia, amount, consistency etc.	To identify post-partum hemorrhage and infection.
Wipe from farthest area to the nearest area of the wound (left side of the wound) using antispetic solution.	Cleaning loosens and removes any dried blood or crusted exudate from the suture and the wound bed.
Wipe from farthest to nearest on the wound.
Wipe from farthest to nearest of the wound (right side of the wound).
Wipe from the lowest part of the wound to anus.
Wipe with dry gauze.	To keep the suture dry.
Discard the waste as per JMMCRI protocol
Remove gloves.
Perform hand hygiene
Document all relevant information in the medical record.

NM2004a - Gestational Hypertension

Gestational hypertension is the hyper tension arising for the first time after 20 weeks of gestation in the absence of proteinuria. The blood pressure return to normal within 12weeks of postpartum.

Management

BP assessment

Urine analysis for proteinuria

Among mothers with gestational hypertension whose blood pressure is less than 140/90, with or without antihypertensive treatment, should not be offered planned early birth before 37weeks until there are medical interventions.

Pre-eclampsia

Pre-eclampsia is associated with new onset of hypertension persistently >140/90 mmHg in 2 occasions 4 hour apart or ≥160/110mmHg in the severe case which occurs most often after 20 weeks of gestation and frequently near term. Proteinuria may or may not present.

Management

Blood Pressure monitoring (left lateral position).

Physical examination (pitting edema, blurring of vision, headache, and epigastric pain.).

Diagnostic laboratory test (LFT, RFT, CT, BT, Platelet, Fibrinogen, PT, APTT, LDH, PBS, urine albumin and protein-creatinine ratio).

Restrict intravenous maintenance fluid to 60ml/hr.

If any variation in the report induce labor.

The mode of delivery determined after considering the presentation of the fetus, the fetal condition.

Wait for vaginal delivery if blood pressure is stable.

Caesarean section if blood pressure is unstable.

In case of pre-term cases, antenatal steroids may be administered for fetal lung maturity.

A prophylactic dose of 4gm Magnesium sulphate (2gm in each buttocks, IM) followed by 4gm in 100ml NS in 20 minutes. Followed by 4gm magnesium sulphate in 100ml NS intravenously over 4 hours can be given.

Magnesium sulfate intravenously for neuroprotection of fetus.

Eclampsia

Eclampsia is an extremely severe form of pre-eclampsia. It is characterized by new onset of focal multi-focal tonic–clonic convulsion or coma in pregnancy or postpartum.

Management

v Control of convulsion

v Control of hypertension

v Delivery of the fetus.

Control of convulsion

Principle of resuscitation (ABCDE)

Prevent maternal injury (raise bedside rails during convulsion)

Maintain cardio-respiratory function

Patient should never be left alone

Lateral decubitus position (to prevent aspiration)

Suctioning of oral secretion and vomitus if needed.

Assess and establish airway patency (to ensure maternal oxygenation).

Supplement oxygen by face mask at 8-10L/min during the seizure. (Reduce the risk of apnea during seizure)

Use of physical restraints if necessary.

Apply oropharyngeal airway to avoid tongue bite.

Pulse oximetry to monitor hypoxemia

Once the seizure ends starts IV fluids. (60ml/hr). Maintain input-output chart.

Give a dose of 4gm Magnesium sulphate (2gm in each buttocks, IM) followed by 4gm in 100ml NS in 20 minutes. Followed by 4gm magnesium sulphate in 100ml NS intravenously over 4 hours.

Continue the magnesium sulphate for 24 hours as per the doctor’s order, if there is no complication.

Continuous assessment of (knee jerk, respiration, urine output is mandatory while administration of magnesium sulphate.

If BP is > 160/110, give IV boluses of labetalol20mg initially then 40mg and then 80mg at 15-minute intervals until BP is in the desired range.

Treatment with magnesium sulphate should continue for 24 hours after delivery in order to avoid postpartum eclampsia.

Control hypertension

Prevent congestive heart failure- diuretics, prevents overload (slow intravenous where indicated).

Prevent cerebral hemorrhage- diagnostic MRI

Delivery of the fetus

Delivery is the only definitive treatment.

Every attempt should be made to stabilize the mother before attempting to deliver.

Preparation for emergency caesarean.

Prepare for endotracheal intubation if necessary.

Antepartum hemorrhage

Antepartum hemorrhage is defined as bleeding from the genital tract in the second half of pregnancy.

Management

Pulse, respiratory rate and blood pressure monitoring every 15 minutes. Monitor urine output and maintain intake output chart.

Administer 6-10 L/minute of oxygen via face mask.

Initiate two18G intravenous lines and20mL blood for diagnostic tests (full blood count, coagulation screen, cross match 6 units, urea, and electrolytes, kleihaur Betke test).

Administer warmed crystalloids and colloids as per the requirement.

Maintain the warmth by providing the appropriate available measures.

Digital examination of the cervix is contraindicated. There is a serious risk of causing major hemorrhage if the underlying cause is placenta praevia. Instead per speculum can be done.

Fetal monitoring (cardiotocography). Ultrasound for placental localization, estimated fetal weight, presentation (only if maternal and fetal condition are stable.

Administer the prescribed prophylactic medication for fetal lung maturity (corticosteroids).

Prepare the patient for delivery.

Post-partum hemorrhage

Management

Observe the characteristic and quantity of blood loss. Bright red is arterial and can indicate the laceration of genital tract. Bard red blood is likely of venous origin and may indicate superficial lacerations or varices of the birth canal. Spurts of blood with clot can indicate partial placental separation.

Weigh the perineal pads before and after use and then subtracting the difference helps to measure the vaginal discharge.1 gm of weight is comparable to 1 ml of blood volume .be sure to turn the client on her side when inspecting for blood loss to be certain a large amount of blood is not pooling undetected beneath her.

Assess the uterine contraction, urinary bladder and cervical tear.

Assess the pain.

Initiate IV access preferably two large bore cannulas.

Active management of third stage of labor.

Assess the lochia for color, quantity and clots.

Monitor vital signs including systolic and diastolic pressure, pulse and heart rate in every 15 minutes. Check for the capillary refill and observe nail beds and mucus membranes.

Measure a 24 hour intake and output .observe for signs of voiding difficulty.

Maintain a nothing by mouth (NPO)

Monitor the client’s oxygen saturation levels.

Observe the color of the nailbeds, gums, tongue, and buccal mucosa. Note the temperature of the skin.

Lower the head of the bed and elevate the client’s legs when lying down or sitting, as indicated.

Administer warmed blood and blood products or IV fluids as ordered to prevent hypothermia.

Monitor for pre-existing conditions like respiratory or cardio issues before administering medication like oxytocic and prostaglandin.

Uterine artery clamp or SR cannula can be arranged for the immediate management.

Prepare the patient for hysterectomy is the last choice in the management of post-partum hemorrhage.

Placental Previa

Placenta previa is when the placenta attaches inside the uterus but in an abnormal position near or over the cervical opening.

Classification

Grade I

Lower placental edge dipping into the lower uterine segment

Grade II

Placental Previa

Lower placental edge up to the margin of the internal OS

Grade III

Placenta partially covers the cervix when not dilated.

Grade IV

Placenta completely covers the cervix even when dilated.

Management

Woman managing with vaginal bleeding should be managed individually according to their needs.

Prepare the patient Caesarean section if at term foe a major degree of placenta Previa during admission.

Placental abruption

Management

Initiate IV access.

Resuscitation with blood and crystalloids and prompt delivery are lifesaving.

Hemoglobin, packed cell volume, grouping, cross matching and coagulation profile, rotational thromboelastometry (ROTEM).

A complete coagulation profile is done which includes fibrinogen, fibrin degradation products, partial thromboplastin time, prothrombin time, and platelet count.

Immediate preparation for the caesarean if the gestational age ≥ 28 weeks if immediate vaginal delivery is not possible.

Arrange for blood transfusion. (Abruption of sufficient severity to lose the baby)

An indwelling catheter is introduced and intake and output monitored closely. Maintain a urine output of at least 30mL/hr.

A central venous pressure line is best inserted in severe cases.

Observe for clot observation time .the normal clotting time is 4 -10min.The clot should be stable. A fragile clot indicates the presence of fibrin.

Cardiotocography monitoring is advocated during labor.

Gestational diabetic mellitus (GDM)

Gestational Diabetic Mellitus is defined as impaired glucose tolerance with onset of first recognition during pregnancy.

Management

Prepare for Caesarean if baby is macrocosmic.

Monitor the blood sugar level as per 4 point profile. Fasting blood sugar before breakfast and post prandial blood sugar respectively one hour after the start of each of the three main meals (breakfast, lunch and dinner).

If blood sugar level is uncontrolled measures should be taken to control level before delivery.

Should monitor GDM positive woman for complication and timely management of complication.

Cord prolapse

Cord prolapse is the presence of umbilical cord through the cervix alongside (occult) or past the presenting part (overt), in the presence of ruptured membrane.

Management

Call for help and ask both obstetric and neonatal emergency team.

Following recognition of cord prolapse, the presenting part should be elevated to minimize cord compression. This can be achieved by maternal positioning (raise the buttocks with pillow), digital elevation of the presenting part or bladder filling.

Administer the prescribed medicine to reduce the uterine contractions.

Avoid handing cord to prevent vasospasm. If the cord is prolapsed out from the vagina, attempt to gently replace it back into the vagina using a dry pad with minimal handling.

Monitor for fetal heart tones and cord pulsations through cardiotocograph.

Preparation for immediate delivery should be made simultaneously.

NM2005a - CARDIOTOCOGRAPHY

DEFINITION

Electronic fetal monitoring is a method of assessing fetal status both before and during labor. The fetal heart rate baseline are obtained and evaluated to identify any abnormalities that can impact fetal wellbeing.

PURPOSE

Continuously assessing the fetal heart rate

Obtaining information about the uterine activity

Information recorded in a graph paper

Allowing minute to minute fetal wellbeing during labor

TYPES

External fetal monitoring/non-invasive fetal monitoring

• Fetal heart rate monitored through ultrasonic transducer

• Uterine contraction is monitored through tocodynamometer

Internal fetal monitoring

• Fetal scalp electrode applied to monitor fetal heart rate

• Intrauterine pressure catheter to monitor uterine contractions

EXTERNAL FETAL MONITORING/NON-INVASIVE FETAL MONITORING

Duration

Ante partum and on admission to the labor.

The usual duration is 30 minutes.

Assessment parameters

Both the fetal heart rate and uterine activity are traced simultaneously onto a paper strip. The relationship of fetal heart rate and the timing of uterine contraction is also assessed.

Components of fetal heart rate

Baseline rate Baseline variability

Accelerations Decelerations

Accepted Normal Parameters

Baseline fetal heart rate of 110 to 160 beats per minute.

Baseline variability should be greater than five beats per minute.

Presence of two more accelerations of the fetal heart rate exceeding 15 beats per minute, sustained for at least 15 seconds in a 20 minutes period. This pattern is termed reactive.

Absence of decelerations.

Potential Adverse Effects

False negative results

Inappropriate interpretation and subsequent false reassurance of fetal well being

False positive results

Unnecessary procedures or intervention for mother and fetus/new born

Articles

CTG monitor

Doppler fetal monitor

Ultrasound Doppler probe

Uterine contraction probe

Ultrasound gel

Probe belt

Dry gauze

Gloves

Hand rub

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient by name and hospital no.
Check gestational age of the patient.
Take the patient to procedure room to perform cardiotocography.
Be with the patient throughout the procedure. Communicate to her how the procedure is done.
Provide privacy.
Perform hand hygiene and wear gloves.
Auscultate fetal heart beat through Doppler fetal monitor and identify the area of gallop sound. (fetal heart rate).
Keep the belt to fix Doppler probe beneath the waist of the pregnant woman.
Apply enough ultrasonic gel on the Doppler probe to remove bubbles between her abdomen and the surface of the Doppler	To minimize the reduction of ultrasonic waves in the air apply enough ultrasonic gel on the surface of Doppler probe
After moving the Doppler probe little by little to find section where the fetal heart beat sounds relatively loud and clear, control the volume so that the heart beat can have a proper loudness.
Put the button at the upper part of the Doppler probe into a hole of the belt to fix the probe.
It takes 2-4 seconds calculating and indicating FHR. When the stable FHR is indicated, start to record it.
Put the uterine contraction probe on the fundus (approximately 10 centimetres away from the navel upward) or on the part that a lump is firstly made at her abdomen.
Put the button projected from the upper part of the uterine contraction probe into a hole of the belt to fix the probe.
The automatic fetal movement extracts proportional to strength and intervals of fetal movements from the received ultrasonic Doppler signal and records it with a uterine contraction graph at recording paper.
Observe the monitor throughout the procedure.
Advice mother to communicate with the baby to obtain an active graph.
Obtain the graph paper.
Remove the probes and clean mother’s abdomen.
Remove gloves.
Perform hand hygiene
Accompany mother to her assigned room.
Discard the waste as per JMMCRI Policy.
Consult the CTG result with the doctor and accompany him/her while communicate the result to the mother and her family.
Document all the information in the nurses record.

NM2006a – FEOTAL DOPPLER SCAN

INTRODUCTION

A Doppler fetal monitor is a hand held ultrasound transducer used to detect the fetal heartbeat for prenatal care. It can be continuous or intermittent, depending on the medical reason. The scan typically last about 20 minutes, but it can take longer depending on the circumstances.

PARTS

Main unit

Display area

Power indicator pight

Power key

Volume up key

Volume down key

Charging indicator

Probe

DC port

Earphone port

WHEN TO PERFORM THE SCAN

· Routine check-up (usually around 32 weeks, but anytime from 26weeks to term)

· High-risk pregnancies (usually 10-12 weeks to check for developmental abnormalities)

· Specific concerns (when suspect issues like foetal growth restriction, placental insufficiency

WHAT THE SCAN CHECK FOR

· Blood flow through the umbilical cord

· Foetal growth and estimated weight

· Development of foetal organs

· Placental function

· Risks of conditions like foetal growth issues, preeclampsia, foetal anaemia and twin-to-twin transfusion syndrome.

PROCEDURE

Identify the patient

Explain the procedure to the patient and clarify the doubts.

Daub ultrasonic gel on the probe face plate to decrease noise and boost up test result.

Feel the fetal position by hand.

Place the working faceplate on abdomen with feasible tight contact.

Adjust the probe position to obtain an optimum audio signal. Wait until sounds is clear and consecutive seconds later, the LCD screen will display the right FHR.

The site of heart of fetus is 1/3 below of navel line as its earlier stage, it then moves upward with increasing of gestational period, and the site of heart of fetus will be a little deviation to left or right with different fetus.

Make sure that the surface of probe should be contacted fully with the skin.

After the sound become clear and stays stable for a few second, the FHR value will appear on the LCD in real time.

Document all relevant information in the medical record.

INSTRUCTIONS

• Do not compress probe too tightly on abdomen surface to avoid to weaken signal.

• When searching for the heartbeat, do not pull the probe on the abdominal surface to avoid the noise.

• Do not put the probe on the strong position where there is strong Placental Blood Sound or strong Umbilical Sound.

• Press power on/off key to start work, press power on/off key again to stop working.

• Do not measure FHR unless audible and identifiable fetal sound has been heard, usually it needs 5 seconds.

• The normal value of the fetal heart rate is 120-160 bpm. 100-120 bpm and 160-180bpm is the critical values which should be paid some attention to.

• When the device is working, volume can be adjusted by volume down key and volume up key.

• After obtaining the required data, please turn off the equipment in time and wipe the gel on the probe and the skin, put the probe into the probe clamp.

• Switch off the device and take out the battery before cleaning and clean as per the JMMCRI policy.

NM2101 – CARE OF NEWBORN

IMMEDIATE CARE OF NEWBORN

The first 24 hours of life constitute a highly vulnerable time, during which the infant must make major physiologic adjustments to extra uterine life. Most neonate’s transition occurs without difficulty during the first 6 to 10 hours of life.

Transitional stages

During the period of postnatal transition, six overlapping stages have been identified.

Stage 1

Receives stimulation (during labor) from the pressure of the uterine contractions and from changes in pressure when the membrane ruptures.

Stage 2

Encounters various foreign stimuli-light, cold, gravity and sound.

Stage 3

Initiates breathing.

Stage 4

Changes from fetal circulation to neonatal circulation.

Stage 5

Undergoes alteration in metabolic process, with activation of liver and GI tract for passage of meconium.

Stage 6

Achieves a steady level of equilibrium in metabolic process (production of enzymes, increased blood oxygen saturation, decrease in acidosis associated with birth, and recovery of neurologic tissues from the trauma of labor and delivery)

PURPOSES

To clear air passage and facilitate breathing.

To observe for any external anomalies.

To provide adequate warmth.

To help the newborn to adapt to the extra uterine environment.

To keep the baby clean.

EQUIPMENT

Suction machine

Mucus sucker

Radiant warmer

Cord clamp

Baby cloth

Baby sheet

Identification tag

Alcohol swabs/alcohol

Sterile cotton balls

Sterile cord cutting straight scissors

Measuring tape

Rectal thermometer

Solution and cotton balls.

Emergency medication

Bulb syringe.

GENERAL INSRUCTIONS

The emergency equipment for neonatal resuscitation is to be always kept ready in neonatal area.

Inj.Nalaxone to be kept ready in case of mother was sedated prior to deliver.

Do not stimulate baby (rubbing the back or suctioning nose and avoid bagging.) if amniotic fluid is meconium-stained.

If any deviation from normal is anticipated, inform doctor. If mother has diabetes mellitus and is on insulin, and if the baby’s weight is less than 2kg or more than3.8kg transfer to nursery.

PROCEDURE

NURSING ACTION	RATIONALE
IMMEDIATE CARE: Place the baby soon after delivery in a tray lined with sterile linen with the head slightly downward.	Facilitates drainage of mucus accumulated in the tracheobronchial tree by gravity.
Place the tray between the legs of the mother at a lower level than the uterus.	Facilitates gravitational flow of blood from the placenta to the fetus.
Clear the air passage off mucus using extractor or bulb syringe.	Maintains patent airway.
Check Apgar rating at 1 minute and 5 minute and record.	Assesses the health status of newborn.
Clamp and cut the cord. Cord is to be clamped, divided and examined following birth of the baby.	Identifies abnormality. Separates the baby from mother for extra uterine life
Dry the baby thoroughly, remove wet linen and wrap the baby in dry, warm blanket/sheet.	Prevent loss of heat by evaporation and chilling.
Tie identification tags which have mother’s name and hospital number on wrists of mother and on leg of baby.	Avoids confusion between staff and chances of wrong identification.
Apply cord clamp or ligature and cut the cord short to desirable length.
Place the baby under a radiant warmer until temperature is stable.	Maintains body temperature.
Clean the eyes with sterile cotton balls soaked in sterile water.
Mummify the baby.
Apply a napkin which should be changed periodically	Moisture increases chances of microorganism colonizing in the skin and cervix.
Check patency of rectum by introducing lubricated rectal thermometer.	Identifies imperforate anus.
Check the weight and length of the baby, the baby should be weighed naked. Weight: Indian baby 2.5- 3.0kg Length: 50cm. Head circumference Chest circumference	Normal measurements
Check vital signs	Identifies any deviation from normal.
Administer vitamin-k, 1mg intramuscularly.	Minimizes risk of hemorrhage and to maintain the normal flora of the gut.
Administer prophylactic antibiotic therapy if ordered, in condition like a) Delivery following premature of membranes. b) Maternal risk factors.	Prevents secondary infection.
Observe the baby frequently at least for 4-8 hours.	Identifies any abnormal signs developing in newborn.
Document all relevant information in the medical record.	Acts as a communication between staff members.

FOLLOW –UP CARE

· Wipe the baby thoroughly every day.

· Measure the baby daily for weight, head and chest circumference.

· Provide eye care if needed.

· Apply expressed breast milk (EBM) 0.5ml 4^th hourly for babies who are not taking orally to avoid

· Change the diaper when it is soiled.

NM2102 - BREASTFEEDING

ASSISTING WITH BREAST FEEDING

DEFINITION

Assisting, educating and supporting the postnatal mother to feed newborn baby at breast and providing breast care to the mother before the feed.

PURPOSE OF BREAST FEEDING

To enable the mothers to feed their babies adequately without discomfort.

To enable the newborn meet his/ her nutritional needs adequately.

To promote mother-baby bonding.

To minimize the chances of developing breast problems due to stasis of milk.

Provide immunological benefits to the baby

Breast feeding and position throughout the life time.

Stimulate all the five special senses in the newborn.

PURPOSE OF BREAST CARE

Clean the breast before feeding the baby.

Observe for any problems in the breast and to help the mother.

Identify breast engorgement and manage it appropriately.

Enhance sucking of the baby.

EQUIPMENT

· Bowl small with lukewarm water

· Bath towel

· Pillows

GENERAL INSTRUCTIONS

Make sure the mother has taken bath.

Instruct her to wash hands before feeding.

Instruct mother to keep the breasts and nipples clean after each feed.

PROCEDURE

NURSING ACTION	RATIOINALE
Identify the patient
Explain the procedure to the mother	Helps the mother to identify and clarify fears and concerns and to correct misconceptions.
Instruct to wash hands before feeding.	Proper hand washing is the most single factor in protecting newborns from infection.
Assemble necessary equipment at bedside.	Helps to promote self-esteem.
Provide privacy
Instruct the mother to clean the nipples and areolar region with a wet wash cloth and dry them. With a soft cloth, clean nipple area then clean breast with lukewarm water. Clean one breast at a time.	Use of soap on nipples is not recommended as it is a drying agent and can lead to cracking.
Assist the mother to assume comfortable position providing adequate support to back.	Reduces discomfort associated with prolonged sitting and promotes mother’s involvement in feeding the baby.
For post-operative mothers , Assist the mother in side lying position.	Facilitate feeding without strain to the incision areas.
Tuck a pillow under her ribs if feeding from the lower breast.	Placing a pillow under the ribs brings baby and breast closer and provides a shield over the incision.
Post vaginal delivery mother who wishes to feed in sitting positions. Instruct the mother a. Cradle hold b. Football hold c. Cross-cradle or modified cradle hold.
For cradle hold: Positions the infants head at or near the ante-cubital space and level with her nipple, with her arm supporting the infants body and with her other hand to hold the breast as required to facilitate sucking from breast.	This would adjust the height so that she need not bend forward.
For football hold: Instruct mother to support the infant’s head in her hand with the infant’s body resting on pillows alongside her hip.
For cross-cradle or modified cradle hold: Assist the mother to sit with her back upright and right angles to her lap. Place a pillow on her lap. Let the mother hold the baby supporting his head with her extended arms.
Move the baby near the breast, turned towards the mother’s body with neck slightly extended and the mouth near nipple.
Let the mother move the baby’s mouth against her nipples.
Cover the proximal breast with the bath towel by spreading it across the chest and under the distal breast	Avoids unnecessary exposure and to protect the mother’s own linen.
As the baby opens his mouth dropping his lower jaw and darting his tongue, insert the nipple and breast tissue inside the mouth, so that the baby latches on to the nipple and areola correctly.	Having the bottom lip about 1.5cm away from the base of the nipple allows the baby to latch on the breast. With this position ,the lactiferous sinuses will be inside the baby’s mouth
Provide assistance as needed to help for correct attachment of the baby to the breast and to start sucking.
Remove the baby from breast. Insert a finger into the corner of sucking infant’s mouth.	Facilitate breaking the suction, avoids damage to nipple.
When the baby releases the breast, burp him.	Burping permits expulsion of swallowed air.
Encourage the mother to feed the baby from the second breast in the same manner.
Burp the baby as he comes off the second breast.
Wrap the baby and lay him on his side in the crib.	Prevents risk of aspiration if the baby vomits.
Replace the article.
Record in the medical record the time and duration of feeding and any observation made.

HEALTH TEACHING

Placement of the baby on the breast should enable him to feed from the breast rather than from the nipple.

The finishing breast at one feed should be the starting breast for the next feeding so that both breasts get emptied.

Feed the baby every two hours for the first one or two days and shorter and frequent after two days. ( that is every 3-4 hours).

Daily bathing and change of dress are important for breast hygiene of nursing mothers.

Breastfeeding mothers need to wear proper fitting brassieres to provide comfortable support of breasts.

Arouse baby in between feeds by stroking the sole of the feet or earlobe.

NM2103a - PALADAI FEEDING

DEFINITION

The paladai is a cup-like utensil with a narrow tip that has been used traditionally to feed babies when the mother cannot breast fed. It is used to hold expressed breast milk or other types of liquids or semi-solids.

The baby is held reclining while being fed.

ARTICLE

Sterile steel bowl small

Paladai

Steel teaspoon

Sterile cup

Powdered infant formula / Expressed Breast Milk

Warm water

Tissue wipes

Measuring cup.

INDICATION

Small for gestational age babies

Premature babies who have good swallowing reflex but poor sucking reflex.

Low birth weight baby.

CONTRA-INDICATION

Congenital anomalies-cleft lip or cleft palate.

Extremely low birth weight below 1000 grams.

Absence of sucking/swallowing reflex.

Semi-conscious/unconscious baby.

Incubator or ventilator baby.

ADVANTAGE

Best method for stable premature and low birth weight babies.

Chances of transmission of infections associated with feeding is less when compared to bottle feeding

It’s a bridge between gavage feeding and direct breastfeeding.

PROCEDURE

· Identify the baby by hospital number and prepare the prescribed amount of powdered infant formula feed or expressed breast milk.

· Baby should be awake and held sitting semi upright position on caregiver’s hand. Wrap small cloth/tissue wipes around the neck to catch drips of milk.

· Put a measured amount of milk in paladai.

· Hold the paladai so that the pointed tip rests lightly on the baby’s lower lip.

· Tip the paladai to pour a small amount of milk into the baby’s mouth at a time.

· Feed the baby slowly.

· Make sure that the baby has swallowed the milk already taken before giving any more.

· When the baby has had enough, he or she will close his or her mouth and will not take anymore. Do not force-feed the baby.

· Burp the baby effectively and comfort him.

· Discard any feed that has not been consumed

· Clean and sterilize the utensils.

· Discard the waste as per JMMCRI policy.

· Document all relevant information in the medical record

PREPARATION OF POWDERED INFANT FORMULA

v Perform hand hygiene.

v Wash feeding and preparation equipment in hot water.

v Sterilize the feeding and preparation equipment.

v Hands should be thoroughly with soap and water before removing feeding and preparation equipment from sterilizer.

v The use of sterilized forceps for handling sterilized feeding and preparation equipment is recommended.

v To prevent recontamination, it is best to remove feeding and preparation equipment just before it is required for use.

v It is best to prepare feeds fresh each time and to feed immediately.

v Prepare the feed on a clean surface.

v Perform hand hygiene.

v Boil sufficient volume of safe water.

v Pour measured hot water, not above 70 ⁰C into a clean sterile bowl small.

v To the water add the prescribed amount of formula. Adding more or less formula than instructed could make the neonates ill.

v Mix thoroughly by stirring with a cleaned and sterile spoon to ensure even mixing.

NM2104a - KANGAROO MOTHER CARE

DEFINITION

Kangaroo care is a technique practiced on newborn, usually pre-term infants where the infant is held skin to skin contact with an adult on the chest.

Kangaroo position: skin-to-skin contact.

· Skin-to-skin contact between the mother and the baby, in strict vertical position between the mother’s breast and under her clothes is known as kangaroo position.

· Mother serves as source of warmth and stimulation.

Kangaroo nutrition: exclusive breast feeding.

· Kangaroo mother care is an important way of maintaining lactation. KMC increases prevalence, breast milk production, duration and rate of exclusive breast feeding.

· It also increases the competence of mother to breastfeed.

ADVANTAGE/ BENEFITS OF KANGAROO MOTHER CARE.

Benefits to the baby

a. Prolonged skin-to-skin contact between the mother and her preterm/low birth weight infant provides effective thermal control with a reduced risk of hypothermia.

b. KMC facilitates physiological stability in baby.

c. KMC reduces apnea, oxygen requirements and risk of infection to the baby.

d. KMC helps in early discharge of babies from NICU thus helps in reducing the risk of nosocomial infection.

e. KMC induces sound sleep in baby.

Benefits to the Mother

a. As the mother is more actively involved in the care of her baby, she is more relaxed and satisfied.

b. KMC promotes better mother-infant bonding.

c. Mothers are less stressed during kangaroo care as compared with a baby kept in incubator.

PRINCIPLES

Provide tactile stimulation.

Keep the infant warm.

Enhance mother’s confidence.

PURPOSES

It improves their health and well-being by promoting effective thermal control, breastfeeding, infection prevention and bonding.

ELIGIBILITY CRITERIA

· All mothers can provide KMC, irrespective of age, parity, education, culture and religion.

· All stable low birth weight babies are eligible for KMC.

a. Birth weight ≥ 1800 gms:-These babies are generally stable at birth.KMC can be initiated soon after birth.

b. Birth weight 1200-1800 gms:-Many babies in this birth weight group have significant problems in neonatal period. KMC can be initiated after few days.

c. Birth weight < 1200 gms: - These babies develop serious prematurity related morbidities. KMC can be initiated once the baby is stabilized.

GENERAL INSTRUCTIONS

· Kangaroo care can be given by either mother or father.

· Encourage the mother to give kangaroo care at least once in a shift for 30-60 minutes.

· The length of skin to skin contacts can be gradually increased.

· Interrupted only for changing diapers.

PREPARATION FOR KMC

· When the baby is ready for KMC, mother and family members should be counseled so that a positive attitude is created for KMC.

· Mother should be provided with a front open gown or any front open light dress that can retain the baby for extended period of time.

· Baby is dressed with cap, socks, mitten and diaper.

PROCEDURE

NURSING ACTION	RATIONALE
Explain the procedure to the mother.	Makes her understand the need for the procedure and to gain cooperation
Provide privacy	Enhancing self-dignity
Wash hands.	Prevents infection
a. Kangaroo positioning · Baby should be placed between the mother’s breasts in an upright position
· Baby’s head should be turned to one side and in a slightly extended position. This slightly extended head position keeps the airway open and allow eye to eye contact between the mother and her baby.
· Hips should be flexed and abducted in a frog position, the arms should position, also be flexed.
· Baby’s abdomen should be at the level of mother’s epigastrium. Mother’s breathing stimulates the baby thus reducing the occurrence of apnea.
· Baby’s bottom should be supported with a sling/binder.
b. Monitoring Babies receiving KMC should be monitored carefully especially in the initial stages. Baby should be monitored for neck position, airway clearance, regular breathing, body color and temperature.
c. Feeding · Mother should be explained how to breast feed while the baby is in KMC position. Holding the baby near the breast stimulates milk production.
· She can express the milk while the baby is still in KMC position.	The baby could be fed this expressed breast milk with paladai, spoon, katori, or nasogastric tube depending on the baby’s condition.
d. Privacy KMC unavoidably requires some exposure on the part of mother. The hospital staff or family members should respect the mother’s sensitivities in this regard.
Check the diaper of the baby, change it if it is wet before placing the baby on the mother’s chest.	Ensure maximal skin to skin contact on mother’s chest.

TIME OF INITIATION

· KMC can be started as soon as the baby is stable.

· Babies with severe illnesses or those requiring special treatment should be managed according to the unit protocol.

· KMC can be provided while the baby is being fed via oro-gastric tube or is on oxygen therapy.

DURATION OF KMC

· Skin-to-skin contact should start gradually in nursery with a smooth transition from conventional care to continuous KMC.

· Sessions that last less than one hour should be avoided because frequent handling may be stressful for the baby.

· The length of skin-to-skin contact should be gradually increased up to 24 hours a day.

· KMC should be continued at home.

NM2105 – EARLY INTERVENSION PROGRAM

Early intervention capitalises on the unique characteristic of neuroplasticity that ameliorates the effect of insult to the developing brain during foetal and early infancy period. Early intervention provides positive sensorimotor experiences and promotes neuro-behavioural maturation which can greatly mitigate adverse outcomes for these at-risk babies. Early intervention includes nurturing care delivered through the antenatal period continuing to the school going age.

For a baby born preterm or sick, the transition from a secure and optimal intrauterine environment to that of a relatively hostile neonatal intensive care unit environment after birth, compounds exposure to adversities to the developing brain. The concept of the early intervention is that the medical care of sick babies should be as close as possible to the nurturing environment of the womb, especially through the early critical period of brain development. Beginning in the antenatal period, early intervention spans through the first 3 year of life.

Critical period and neuroplasticity

Development of the brain’s basic architecture, neuronal proliferation and neuronal migration to the cortical surface is pre-programed. It occurs before 20 weeks of gestation, and is unlikely to be affected by external sensory stimulation. The period from around 22 weeks of gestation onwards through the first two years of life, is the critical period of brain development when rapid expansion, synaptogenesis, apoptosis, myelination, neuronal organization and alignment take place. These process are extremely sensitive to in experiences and sensory stimulation. Any biological or medical insult that occurs during this critical period like intense, stressful and unexpected sensory experiences in the neonatal ICU is detrimental to brain development and will adversely affect neuro-outcomes.

Principles

Gestational age- appropriate interventions

The timing and type of interventions prior to 40-44 weeks should mimic the intrauterine environment. Active interventions prior to term age can be a source of stress, due to unfavourable changes in catecholaminergic content of the cortical and subcortical regions. The brain should not be overstimulated.

It is prefer to deliver the interventions by the parents with support from health care providers.

Assessment and observation behaviour:

· Stress behaviour like back arching, finger splaying, startle, twitch, flailing, crying, gaze aversion or autonomic disturbances like changes in heart rate and SpO_2.

· Self –regulatory behaviours like putting hand to mouth, foot bracing, sucking on tube, putting hands to face etc. These are ways by which infants attempt to soothe themselves and reflects coping mechanisms in response to stress.

Steps

Supportive positioning and handling

Fetus naturally assumes flexed position in utero in third trimester. Babies born extremely preterm lack adequate muscle tone and strength which causes them to maintain their bodies in extended positions. If left unattended without supportive positioning, it may affect musculoskeletal integrity leading to motor developmental delay, and/or positional deformities like plagiocephaly or torticollis due to prolonged periods of lying in the supine or a single position.

The aim of good positioning is to mimic third trimester posture by promoting flexion, midline orientation, good alignment, and support for movement. Proper positioning positively affect sleep, promotes calmness and a controlled behavioural state. Swaddling improves motor performance, postural development, and movement across the midline, sleep, self-regulation during handling, and decrease stress.

· The prone position facilitates flexion and early head control, improves sleep, decease pain and stress behaviours.

· Supine positioning with a nest containing boundaries made from rolled towels/ positioning aids comfort to the baby. The supine position promotes development of visual skills, symmetrical alignment of arms and legs and self-soothing behaviours like bringing hands to mouth.

· The side lying position is the closest to the fetal position with minimized hip abduction and retraction of shoulders. This improves physiological stability and decreased stress response.

· Upright positioning after 35 weeks post-menstrual (PMA) age, helps to spontaneous head righting and improves exploratory movement of extremities.

· Hammock positioning facilitates midline posture and decrease stress behaviour. Neonate is placed in a rectangular cloth (hammock), which is attached to the extremities of incubator. This positioning simulates intrauterine position, and thus stimulates flexion and promotes symmetry.

Sensory environment, stimulation and interaction

Auditory

Ambient aberrant noise generated by various equipment, alarms and personnel induce stress, autonomic changes and sleep disruption, sensory neural damage, and may contribute to language or auditory processing disorders. Auditory interventions like exposure to language, maternal voice and music can be begun at the post menstrual age (PMA) of 30-32 weeks.it improves feeding behaviour, reduces stress response and improve neurodevelopment. Ambient sound level should not exceed an average of 45dB. This can be achieved by holding quiet conversations at baby’s bed, silencing alarms promptly, avoiding use of headphones/ earphones/mobile phones, and handling doors and carts gently.

Tactile

Preterm <32 weeks are extremely sensitive to tactile inputs and show diffuse behavioural response. The painful procedural experiences in the NICU can develop sensory integration deficits in preterm babies which may later manifest as tactile hypersensitivity, exaggerated hand and toe grasp, or leg withdrawal.

There are four tactile interventions.

· First, Gentle Human Touch (GHT) which involves placing one hand over the baby’s head and the other hand on lower back and buttock for 10-20 minutes, which can be accomplished by the mother during provision of daily care.

· Second, Massage therapy that involves gentle yet firm touch, stroking or rubbing the infant with hand using light to moderate pressure; with or without oils.

· Third, holding for short duration and fourth kangaroo care which provides a multisensory exposure and physiological, neurobehavioral and psychosocial benefits.

Kinaesthetic

Kinaesthetic stimulation pertains to perception of body movements and body position like physical activity, passive movement and joint compression. When infants are tightly swaddled, they are unable to demonstrate their normal writhing movements freely which could interrupt the sensory experiences associated with them. Initiating early free movement (movement initiation therapy) at the earliest time points is consistent with the emergence of fetal general movements.

Gustatory or olfactory senses

Marked alteration in oro-gustatory environment due to differences in the composition of amniotic fluid, and breast or formula milk, along with stressful procedures and placement of orogastric / endotracheal tubes in preterm babies can lead to negative oral experiences and feed aversion. Unpleasant odours arising from the hospital environment can negatively impact the development of smell or taste.

Non-nutritive sucking (NNS) and oro-motor Stimulation (OMS)

Non-nutritive sucking involves sucking on emptied breast. It facilitates smooth transition to oral feeds in preterm babies. Oro-motor stimulation increases the feeding tolerance and improved transition from tube feeding to breast feeding. This stimulation program involves assisted and resisted movements of oro-facial muscles, facilitated coordinated movement of cheeks, lips, gums, tongue and palate, and digital stroking of the same.

Vestibular

The fetus gets vestibular stimulation through maternal movements and gentle oscillations of the amniotic fluid movement. Lack of normal vestibular stimulation in early development can affect general neurobehavioral organization and cause gravitational insecurities and deficits in balance and coordination. Vestibular stimulation consists of rocking and infant swings for 3-7 minutes at 33-34 weeks post menstrual age (PMA).

Visual

Since the womb is dark, bright ambient light exposure is stressful to babies. Visual interventions include modifying the light environment through dim, bright or cycled light. Prior to 32 weeks post menstrual age (PMA) dim environment is whereas cycled lights can be started at 32 weeks post menstrual age (PMA).

Reduced stress and pain

Exposure to repeated painful procedures in early life can lead to altered brain development with impaired cognition, behavior and emotional regulation as well as altered pain perception.

Promoting and protecting sleep

Undisturbed sleep is essential for weight gain and optimal brain growth. All non-emergent care giving activities should be provided during wakeful states.

Skin care

Optimal skin care involves assessment and documentation of skin integrity by nursing staff at least once per shift. Thorough skin assessment has to be done to avoid pressure injury.

Nutrition

Breastfeeding may be challenging in small and sick neonates due to mother –infant separation, motor or physiological immaturity. Human milk has a positive impact on preterm infant’s neurodevelopmental outcomes. Enteral feeding with expressed breast milk or donor human milk has to be started immediately

Parenting with parents and families.

Care to small and sick neonates must be delivered by parents and supported by healthcare providers. The family must participate in activities like KMC, holding, feeding, dressing, diapering, singing etc.

Being born too small or too sick interrupts the nurturing care and environment that a fetus was enjoying being in mother’s womb. So nurturing care in the neonatal period is the key to optimal early childhood development.

NM2106a - CARE OF BABY IN PHOTOTHERAPY

INTRODUCTION

Phototherapy is the use of visible light to treat severe jaundice in the neonatal period. It is a safe effective method for decreasing or preventing the rise of serum unconjugated bilirubin levels and reduces the need for exchange transfusion in neonates.

PURPOSE

Phototherapy light converts the built-up bilirubin (Z isomer) to water-soluble bilirubin (E isomer)

For effective phototherapy three factors must be observed.

Spectrum of light

Wavelength of 460-490nm is effective in breakdown the bilirubin.

Sufficiency high irradiance

The appropriate height is 30cm (12 inches).

Sufficient surface area

Widespread coverage of phototherapy light is required.

EQUIPMENT

Phototherapy machine.

Eye shield

Napkin to cover baby genitalia.

Baby sheets.

INDICATIONS

Elevated serum bilirubim levels:

Healthy term babies > 17mg/dl

Preterm babies (weighing more than 1500g :> 8mg.dl

Preterm babies (weighing less than 1500g :> 5mg/dl).

METHOD

Fluorescent lamps/ bili lights placed over the infant who is usually in an incubator or under a radiant warmer.

Halogen lamps.

Fiberoptic phototherapy blankets or pads.

PROCEDURE

NURSING ACTION	RATIONALE
Provide explanation to mother that her baby will be kept in an isolate and exposed to a blue green light for bringing down the bilirubin level.	Allays anxiety and convinces her about the need for phototherapy.
Instruct mother to feed the baby.	Prevents dehydration when exposed to phototherapy.
Check the incubator and bili lights for electrical safety and proper insulation of wires.	Prevents electrical hazards.
Check whether all bulbs are burning in the incubator.
Transfer the baby to nursery where phototherapy equipment is present and place the baby in the bassinet over which phototherapy lights are placed.	Heat loss is minimized and temperature is controlled when an incubator is used.
Adjust height between baby and lamp to 45cm.	Lights that are too close increase the risk of burning the skin. Lights too far away from the infant will not be effective.
Place baby naked under light in the bassinet.	Express the skin as much as possible for maximum exposure to light.
Cover the baby’s eyes with eye pads.	Protect eyes from the effect of high intensity lights on retina and avoids abrasions to cornea.
Cover the genitals of baby with the napkin.	Protects testicles from the high intensity lights.
a. If fiber-optic pad is used, place it under the baby in contact with the baby’s skin. b. Keep the baby on his side. With a rolled baby sheet on the side.	Aids in maximum exposure of skin surface Maintains the position
Switch on bili lights and/or machine for the fiber--optic pad.
Change position every two hours.	Ensures that light reaches all areas of the body.
Record in baby’s medical record, all details about starting the procedure, observations made and precautions taken.	Acts as a communication between the members.

CARE AND OBSERVATION DURING PHOTOTHERAPY

Provide feeding at regular intervals to maintain adequate hydration. If breastfeeding, mother should be encouraged to give demand feeding.

If baby is hyper thermic, discontinue phototherapy and keep baby exposed under fan. When temperature reaches normal, restart phototherapy.

Monitor bilirubin level and other hematologic assessments at regular intervals.

Check baby at least every hour and see that the eye shields remain in place.

The infant may be removed from the lights for feeding, diaper changes, blood draw and other general care but should receive phototherapy for 18 hours every day.

Do not apply oil to the skin of the baby.

If fiber-optic blanket is used, it should be kept next to baby’s skin at all times. Be sure that the baby does not roll off the blanket, it is not necessary to cover the eyes if blanket alone is used.

Monitor body temperature at regular intervals.

Observe the skin for rashes, dryness and excoriation.

Feed the baby every 2-3 hours because phototherapy causes the baby skin dry at all times. Be sure that the baby does not roll off the blanket. It is not necessary to cover the eyes if blankets alone are used.

Count your baby’s wet diapers and stools. Increase feeding if the baby has less than six-wet diapers a day or if urine appears dark.

Observe for side-effects like:

· Loose green stool resulting from increased bile flow and peristalsis. Stool may damage the skin and cause fluid loss.

· Tanning effect from the lights.

· Bronze baby syndrome-a grayish brown discoloration of skin and urine.

· Skin rash.

· Temporary lactose intolerance.

NM2107a - CARE OF BABY IN INCUBATOR

INDICATION

When they are not maintain their own temperature with clothing and wrapping.

When they are acutely unwell and close observation is required.

When they are at risk of abnormal heat loss.

They have a known infection/or the potential to develop sepsis.

There are nutritional concerns (given that infants use a large proportion of their calorific intake for maintaining their temperature.

They are small for gestational age.

They have a large wound site.

New stoma (not always indicated) or exposed bowel

PROCEDURE

NURSING ACTION	RATIONALE
Prepare the incubator Pre-warmed to a temperature appropriate to the infant’s age, size and condition. Use in Air mode and must always be switched on with the motor running if in use for a baby. Check and record the incubator temperature hourly. Position away from draughts or direct sunlight Do not routinely use on the humidity function while in use for a baby. Ensure self-test has been completed.
Care of baby Maintain axilla temperature between 36.5⁰C and 37.2⁰C Access baby by using the portholes, limit opening of large door as this interferes with air temperature. Ensure baby is nursed naked apart from a nappy. Position baby utilizing rolled towels/ cloth nappies to provide boundaries that support nesting and flexion of limbs but keeping face clear.
Explain to parents/ caregivers the purpose of an incubator for their baby: Ensure they are familiar with how to access baby as it is optimal for parents to continue to touch and provide comfort. Maintain a quiet environment There is no tapping on the canopy No equipment placed on the top of the canopy. Careful opening and closing of the doors.
Adjusting incubator temperature. Default incubator temperature in NICU is 35 degrees. Adjust the incubator temperature by no more or less than 0.5 of a degree at a time. Re-check the temperature within half an hour of making any adjustment.
Monitoring Axilla temperature is taken on admission into the incubator and rechecked in the first hour. Temperature is documented 4-6 hourly as condition dictates.
Use of humidification: Is utilized for incubator care of preterm babies only- NOT required for babies > 32 weeks.	Stressed babies are prone to stress both

WEANING INCUBATOR TEMEPERATURE IN PREPERATION FOR COT CARE

PROCEDURE
NURSING ACTION	RATIONALE
The incubator temperature should be weaned by 0.5 degrees until 30 degrees is achieved. Baby can be transferred to a mother side after wrapping with the cloth. Check temperature within one hour of transfer.

CARE OF INCUBATOR

PROCEDURE
NURSING ACTION	RATIONALE
Wipe down daily using minimal soap/water. Do not use alcohol. Incubator is changed every 7 days. Incubators are cleaned with hot soapy water; all inserts are removed and thoroughly washed and dried. Filters are changed every 3 months.

NM2108a - CARE OF BABY IN RADIANT WARMER

INTRODUCTION

The radiant warmer (also called open care system) was developed as an ‘open incubator’ that ensures ready access to the baby. It act as an intense source of radiant heat energy.it also reduces the conductive losses by providing a warm microenvironment surrounding the baby.

The overhead quartz heating element produces heat which is reflected by the parabolic reflector on to the baby on the bassinet

MODES OF RADIANT WARMER

Servo mode

In this system the heater output from the heating quartz heating rod is determined automatically based on the skin temperature information.

Manual mode

In this system the heat output from the heating quartz heating rod can be increased or decreased manually by the heater control knobs.

PARTS OF OPEN CARE SYSTEM

Ø Bassinet

o To place the neonate

Ø Quartz rod

o To provide radiant heat

Ø Skin probe

o To display skin temperature when attached to the baby’s skin.

Ø Control panel

o Has a collection of display and control features/knobs.

Ø Heater output display

o To exhibit heater output.

Ø Heater output control knobs

o To increase or decrease heater output manually.

Ø Temperature selection panel

o To select either set temperature or skin temperature

Ø Temperature selection knobs

o To select a desired set temperature

Ø Temperature display

o To display temperature as selected, either of the baby’s skin (via skin probe) or the set temperature.

Ø Mode selector

o To select manual or servo mode

STEPS FOR USE OF WARMER

Ø Connect the unit to the mains. Switch it on.

Ø Select the manual mode

Ø Select heater output to 100% for some time to allow quick pre-warming of the bassinet covered with linen.

Ø Select servo mode

Ø Select the desired set temperature of baby as 36.5°C.

Ø Place the baby on the bassinet.

Ø Connect skin probe to the baby’s thigh with dry gauze.

Ø If the manual mode to be used, select the desired heater output.

APPLICATION OF SKIN PROBE

· Apply probe around the thigh and fix it with the gauze.

· Check sensor probe regularly so as to ensure that it is in place. Ensure that skin probe is free of contact with bed.

· Ensure that the area where the probe is applied, is dry.

· Don’t apply the probe to the bruised skin.

· Do not apply clear plastic dressings over probe.

· Do not use the fingernails to remove the probe

· Use of cling wrap (transparent polythene) over the baby, tied across with the panels of warmer helps to reduce the insensible water losses and result in better thermal control of very low birth weight.

· If the probe is displaced from the baby’s skin, overheating of the baby will occur because the skin probe depicts air temperature and heater output keeps on increasing till probe temperature matches control temperature.

· Change the servo mode to manual when the baby develops to fever.

· Don’t use the warmer in cold room. It works better when the environmental temperature is above 20⁰C.

· Ensure that the baby’s head is covered with cap and feet secured in socks and the baby clothed or covered unless it is necessary for the baby to be naked or partially undressed for observation or for a procedure.

· Keeping the warmer where there is lot of air currents reduces its efficiency.

· The warmer must be pre-warmed around 20 minutes before the arrival of the baby or till the set temperature is reached with less than 50% of total heater output.

· While using the manual mode in a warmer without a temperature display, record the baby’s temperature regularly, preferably 2^nd hourly.

· Once the body’s temperature is between 36.5⁰C to 37.5⁰C, switch on the servo/ skin mode

· Clean all the approachable external surfaces should be cleaned daily with an antiseptic solution as per JMMCRI policy.

NM2109 – ASSISTING IN UMBLICAL ARTERY & VEIN CATHETERIZATION, CARE & REMOVAL

Umbilical vein catheterization utilizes the exposed umbilical stump in a neonate as a site for emergency central venous access up to 14 days old. Umbilical vein catheterization. Can provide a safe and effective route for intravenous delivery of medication and fluids during resuscitation.

INDICATION

Continuous arterial blood pressure monitoring

Arterial blood gas sampling

Blood sampling for other laboratory studies

Exchange transfusion

Angiography

Infusion of maintenance and hypertonic fluids

CONTRAINDICATION

Omphalocele

Gastroschisis

Omphalitis

Peritonitis

Evidence of vascular compromise in the lower limbs/buttocks and necrotizing enterocolittis

POSITION

· The newborns should be restrained in a supine position and placed beneath a radiant warmer.

· The length of catheter measurement for this is the distance in centimeters from the shoulder to the umbilical is measured.

EQUIPMENT

Requisite intravenous fluid

Syringe

Appropriate size catheter for preterm and 5F UA/UV catheter for the term babies.

Antiseptic solution

5cc syringes

3-0 silk suture curved needle, umbilical tape

Disposable umbilical catheter

Surgical gowns, masks and gloves

Sterile drapes

Adhesive tape and tape measures

Heparinized saline

Sterile linen cord tie

Sterile tray containing

Straight Artery forceps

Artery Curved forceps

BP handle

Disposable scalpel blade no.11

Curved mosquito forceps

Probe

Suture straight scissors

Needle holder

Toothed forceps

Small curved tissue forceps

Straight mosquito forceps

Six small towel clips

Folded towels

4X4 gauze pads.

PROCEDURE
NURSING ACTION	RATIONALE
Identify the patient.
Explain the procedure to the parents.	Gains confidence and cooperation.
Position the neonate under the warmer.	Maintains warmth and prevent hypothermia thoughout the procedure.
Assemble the article near the warmer.	Ease the procedure.
Determine the size and type of catheter to be used.
Assist the doctor to measure the shoulder to umbilicus length	It helps to determine the depth of the insertion of the catheter.
Perform hand hygiene.	Reduce the risk of contamination
Wear sterile gown, mask and gloves.	Prevents cross infection and to maintain sterility in the procedure.
Clean the site with aseptic solution.	Makes the area free of micro-organisms.
Place sterile towel around the umbilicus and secure with towel clips.	Maintains a sterile environment and reduces the chance of infection.
Prepare the catheter under sterile conditions by connecting the 3 way stopcock at the end.
Flush the system with heparinized solutions	Prevents air emboli after introducing the catheter.
Make the assistant to hold the umbilicus upright with the cord clamp, while the physician cleans the cord and the surrounding skin with antiseptic solution.	Enable the physician to clean the area well
The umbilical cord around the base of the cord and tighten securely.	Avoids bleeding after umbilical stump is cut.
Cut the umbilical stump horizontally 1.5-2cm above the abdominal wall.	Accesses the umbilical blood vessels easily.
Assist the doctor blot the cord if oozing continues.
Identify the umbilical artery and carefully dilate with the vein dilator.	Dilator helps to introduce the catheter freely into the lumen.
Assist the doctor gently insert the catheter into the dilated umbilical artery lumen.	Umbilical arteries are identified by their thick walls with a smaller lumen. Umbilical veins are identified by their position at 12’o clock and large thin walled appearance.
Remove the half curve iris forceps, once the catheter is advanced into the lumen to 2cm, if not advanced to 2cm dilate the vessel again.
Continue to advance the catheter to 4-5cm depth and aspirate to verify position of the catheter in the lumen, then flush the catheter by injecting heparinzed saline.	To ensure there is no air present in the catheter and to prevent clotting.
Confirm radiological the placement of the catheter once the catheter has been advanced to the predetermined depth. The catheter tip should lie above the level of the diaphragm between thoracic vertebrae T6 and T9.	To determine position.
Verify the correct position; secure the catheter in place using a purse-string suture through the adhesive tape and bridge.	This method avoids damage to fragile skin particularly of preterm newborn.
Loosen and remove the adhesive tape once the catheter is secured.
Connect the prescribed fluid under sterile technique.
Watch for bleeding from umbilical cord. Position the baby comfortably.
Replace the articles and discard the waste as per JMMCRI policy.
Perform hand hygiene.	To reduce the risk of contamination.
Document time, duration, condition of the baby and vital signs in the medical record.	Serves as a communication between staff members.

Care of umbilical vein or artery catheter

· Monitor the umbilicus to ensure no bleeding, purulent discharge or peri-umbilical cellulitis

· Ensure the catheter remains adequately fixated and is securely attached with no tension applied to the lines following change of position.

· While changing the position of the baby, it may be necessary for two people with one person caring for the line whilst the other adjusts the position.

· Maintain the patency to prevent blockage or occlusion.

Removal of umbilical vein or artery catheter

· Remove the catheter when it is no longer needed.

· Ensure that a peripheral line is present.

· Stop the infusion.

· Gather all supplies and equipment needed for removal.

· Perform hand hygiene and put on gloves.

· Hold the umbilical cord securely with the forceps and cut the sutures with the straight scissors, taking care not to cut the catheter itself.

· Place one hand gently on the abdomen at the base of the umbilical stump to provide stability, use the other hand to pull out the catheter in a slow (about 2 minutes) and steady manner.

· If any one of catheter is removed, care must be taken not to dislodge the other one.

· Ensure tape the remained firmly secured to the skin.

· Inspect the catheter to ensure catheter is complete and document the same.

· Control bleeding by applying gentle pressure superior to stump site for 5 minutes using sterile gauze.

· The infant should remain supine for 6 hours to observe stump for excessive ooze/hemorrhage.

· Discard the waste as per JMMCRI policy.

· Perform hand hygiene.

· Document all relevant information in the medical record.

COMPLICATION

· Catheter malposition

· Vascular accident

· Hypertension

· Air embolism

· Infection

· Bleeding

· Vascular compromise

· Peritoneal perforation

· Cardiac arrhythmias

· Tamponade

NM2111 - CARE OF PATIENT WITH HEATED HUMIDIFIED HIGH FLOW NASAL CANNULA (HHFNC)

INTRODUCTION

Nasal high flow is a mode of non-invasive respiratory support for pre-term infants, with several potential modes of action, including generation of distending airway pressure, washout of the nasopharyngeal dead space, reduction of work of breathing, and heating and humidification of inspired gas.

DEFINITION

High flow nasal cannula are small thin, tapered bi-nasal tubes that deliver oxygen or blended oxygen/air at gas flows of more than 1L/min.

ADVANTAGES OF NASAL HIGH FLOW

Reduced nasal trauma

Ease of set-up and use for staff

Infant comfort

Easier access to parenteral feeding and skin-to –skin care

Reduce work of breathing

Wash out the dead space (pharynx, nasopharynx, larynx up to terminal bronchiole)

Increased functional residual capacity (up to 25%)

INDICATION

Respiratory distress syndrome

Bronchopulmonary dysplasia

Post extubation support

To aid weaning from CPAP

CONTRAINDICATION

Respiratory failure

Inability to protect airway

Severe hemodynamic instability

Uncontrolled vomiting or copious gastrointestinal bleeding

Total upper airway obstruction (tumor)

Trauma

Pneumothorax

Cranial and airway anomalies

MECHANISM OF ACTION

· Generation of distending pressure

· Washout of the nasopharyngeal dead space

· Provision of adequate gas conditioning.

· Support to the pharynx and splinting of the upper airways.

· The heated and humidified gas decreases the metabolic work of breathing and reverse the dryness and mucosal injury that would otherwise occur at high gas flow rate.

· Delivery of positive distending pressure to the airway recruits alveoli and stabilizes the both large and small airways and the alveoli at end-expiration thus maintaining Functional Residual Capacity. This in turn improves oxygenation and decreases the work of breathing.

EQUIPMENT

Oxygen and air sources

Blender: FiO2 can be adjusted in increments of 1% from 21- 100%.

Humidifier: should be set at 37⁰C. At flow rates of 1-4L/min.

Circuit tubing to attach to humidifier.

Nasal cannula to attach to humidifier circuit humidifier.

Water bag for humidifier.

Flowmeter

INITIATION OF NASAL CANNULA

Choosing an appropriate size cannula:

Nasal cannula should occupy less than 50% of the area of the aperture of the nostril to allow ample egress of expired gas. A snugly fitting or tight nasal cannula can lead to generation of inadvertently high distending pressure in the nasopharynx.

Different sizes are

Red –premature baby

Yellow – neonates

Violet -infants

Setting flow rate:

An initial flow rate of 4-6L/min is recommended. Flow rate based on current weight of the neonate as follows:

FiO2: Begin at 21% or FiO2 similar to ventilator settings.

Conditioning of respiratory gases: the humidifier should be at 370C

Monitoring during therapy: respiratory rate, heart rate, chest retractions and degree of chest- in drawing.

Escalation of therapy: flow rates can be increased in increments of 1L/min up to a maximum of 8L/min in response to increased chest retractions, tachypnea, and increased oxygen requirement.

PROCEDURE

· Identify the patient.

· Explain the procedure to the patient’s family.

· Arrange the article near the patient’s side.

· Slide the humidification chamber onto the humidification base.

· A continual feed of water should be going to the humidification chamber to prevent a water-out alarm or a low-humidity alarm

· Attach the air and oxygen tubing to the central supply and to the blender.

· Connect blender to the humidifier.

· Connect the circulatory line to the humidification chamber.

· Connect the breathing circuit to the humidification chamber.

· Connect the heater wire adapter and the outlet temperature probe to the breathing circuit socket.

· Set the temperature at 37⁰C. Connect the temperature probe to the blue socket and the heater wire adapter plug to the yellow socket on the humidifier base.

· Connect the airway temperature probe to the nasal cannula.

· Connect the patient interphase

· Check arm humidifier base and select the mode.

· Set the same FiO₂ if the baby is on another non-invasive respiratory support or 5-10% higher of previous respiratory support.

· Initiate gas flow before connect it to the baby.

· Place a thin strip of transparent adhesive over baby’s nasal septum and upper lip.

· Place HHHFNC cannula over nasal septum.

· Insert the prongs to the baby’s nares and secure the nasal cannula on the face.

· Allow appropriate gap between base of prongs and nasal septum.

· Discard the waste as per JMMCRI policy

· Document all relevant information in the medical record.

NM2112 – BUBBLE CPAP

CPAP

Continuous positive airway pressure (CPAP) or continuous distending pressure (CDP) is a modality of respiratory support in which increased pulmonary pressure is provided artificially (during both phases of breathing) in spontaneously breathing neonate.

Bubble CPAP is a gas flow mixture .It is warmed and humidified and flows from a wall to the infant.

It is administered via mask or nasal prongs. The expiratory limb of the system is submerged in a sterile water chamber at the desired depth in centimeters that produce positive end expiratory pressure.

Oxygen flow rate ranges from 3-10L/min and adjusted until the gaseous bubbling is seen. The higher the flow, the more the bubbling.

INDICATIONS

· Preterm (HMD, pneumonia) and term infants with tachypnea, retractions, and grunting.

· Recurrent apneic episode

· Prophylactically in extremely preterm babies

· Post-extubation support

· Respiratory distress with Downey’s score >6

CONTRAINDICATIONS

· Poor or absent respiratory efforts

· Hemodynamically unstable baby

· Arterial pH less than 7.25 and paCo2> 60mm Hg

· Congenital malformations or abnormalities where positive pressure therapies are contraindicated (e.g. diaphragmatic hernia, tracheo-osephageal fistula).

· Congenital abnormalities or malformations where binasal prongs or nasal mask are contraindicated. (E.g. Choanal atresia).

· Cleft palate

· Nasal trauma /severe deformity that might be exacerbated by use of nasal prongs or nasal mask.

NOTES

· Do not add or modify any attachments or accessories to the humidifier that are not specified or approved for use with the humidifier or accessory.

· The water source must be at least 50cm higher than the chamber.

· Ensure any unused ports have their caps and/or plugs in place before use.

· Do not use an in-line nebulizer between the pressure relief manifold and the dry side of the humidification chamber.

· Do not bypass pressure relief or valve as this may cause damage /injury.

PART OF BUBBLE C-PAP

· Circuit

· Humidification chamber

· Pressure manifold.

· Generator

Circuit

It includes inspiratory circuit of 1.1/1.4meter and expiratory circuit of 1.2meter.

· Check that heater wire is evenly distributed along the blue inspiratory tube and is not bunched or kinked.

· Check all connections are tight before use and after any adjustment.

· Do not cover the circuit with materials such as blankets, towels or bed linen.

· Do not stretch or milk the tubing.

· Do not crush or pinch the tubing.

· Avoid prolonged contact with patient skin.

· Test circuit for occlusions and pressure leaks before connecting to the newborn.

Humidification chamber

The chamber is to be supplied with sterile water, from a flexible bag or rigid water container.Do not add other substances to the water.

· Do not use the chamber if the seals are not intact when received or if it has been dropped.

· Do not spike the water source until the blue caps have been removed.

· Ensure the humidifier is mounted below the level of patient.

· Ensure there is water supply connected to the chamber and the water is present within the chamber.

Pressure relief manifold

The pressure manifold incorporates a pressure relief valve which activates automatically in the event of a downstream circuit occlusion and which resets upon restoration of normal circuit pressure.

· To reduce the risk of unsafe circuit pressure, the pressure manifold must be used.

· Do not connect the pressure manifold to the outlet port of the humidification chamber as incorrect operation of the pressure relief mechanism may occur.

Generator

CPAP generator is capable of producing CPAP levels from 3-10 cmH₂O.This produces CPAP with pressure oscillations.

· The number directly above the CPAP generator indicates the CPAP pressure set.

· Ensure audible continuous bubbling is maintained.

· If the CPAP generator is not bubbling the CPAP pressure will be less than the amount set.

· Ensure the CPAP generator is mounted below the level of the patient.

PROCEDURE

1. Insert humidification chamber

a. Slide the chamber onto the humidifier base.

b. Remove the blue caps.

2. Connect waterbed

a. Hang the water bag, unwind the water feed set and spike the water bag.

b. Open the vent on the vented spike.

c. Check the humidification chamber for water flow from the bag.

d. If no water is visible on the chamber check that the bag is spiked properly and that the feed tube is not kinked or blocked.

e. Ensure that the height of the water bag is at least 50cm higher than the humidification chamber.

3. Fill bubble CPAP generator

a. Using the fill funnel provided, fill the bubble CPAP generator until water flows into the overflow container.

b. Set the CPAP probe to 10 ready for the leak test.

4. Connect the bubble CPAP pressure manifold and breathing circuit.

a. Connect the oxygen tubing between the pressure manifold and the flow source.

b. Connect the pressure manifold to the chamber inlet port.

c. Connect the blue inspiratory port to the remaining chamber port.

d. Remove the blue caps from the inspiratory tube and connect the temperature probes and the heater wire adapter.

e. Connect the test elbow to the expiratory and inspiratory tubes.

f. Connect the expiratory tube to the CPAP probe.

5. Leak test

a. Check all connections are tight before use.

b. Set input flow rate to 1L/min

c. Observe the CPAP generator. Gentle, audible bubbling is acceptable, no bubbling means unacceptable leakage.

d. If no bubbling is observed, check the entire system.

6. Set flow rate

a. Adjust the flow rate to the prescribed input flow rate

Recommended 6-8L/min

Allowable flow range: 4-15L/min

7. Set CPAP level

a. The number on the probe above the lid indicates the CPAP pressure in cmH₂O.

b. Set the CPAP probe at the prescribed level. (3-10cmH₂O).

8. Connect the bubble CPAP circuit to infant interface.

a. Remove the flow test elbow and connect the circuits to the infant interface using the instructions provided with the interface.

b. Either interface or short binasal prongs (Hudson prongs) is used.

9. Set the humidifier

a. Ensure there is air flow present before turning on the humidifier.

b. Turn the humidifier

c. Set the temperature to 37⁰C.

10. Attach interface to infant

a. Connect the interface to the infant.

NURSING CARE.

· Regularly observe that the water is feeding into the humidification chamber.

· Should the water level exceed the maximum level marked on the humidification chamber, the chamber should be replaced.

· Check all connections are tight before use and after any adjustment.

· Ensure air flow is present at all times. If air flow is interrupted, turn off the humidifier.

· Regularly observe the circuit for condensate. Drain as required in order to maintain set CPAP.

· Regularly observe the CPAP generator for bubbling, If bubbling is not observed check for and minimize air leaks in the system and at the patient. If air leak has been minimized, air flow may be increased to achieve continuous bubbling.

· Regularly observe the water level in th CPAP generator and overflow container. Refill the CPAP generator if the water level drops below the minimum water level line.

· Check and empty overflow container once every 8 hours.

· Monitor patient oxygen levels.

· Change circuit weekly.

· Ensure patency of nasal prongs, suctioning can be done.

· Monitor for nasal trauma.

· Consider elective tube changes if secretions are thick and copious

· Ensure that the strapping is not loose.

· Do not put a saline lavage into the prongs as this will result in aspiration which cannot be removed from the lungs.

· Care must be taken while giving enteral feeds via nasal/ orogastric tube due to the increased risk of abdominal distension, increased chances of venting/ aspiration.

· Use portable ventilator while transporting the baby for scanning or imaging.

· Adequate attention to pressure area care should be given especially to nostrils and nasal septum.

· Discard the waste as per JMMCRI policy and perform hand hygiene.

· Document all relevant information in the medical record.

ASSIST IN DOUBLE VOLUME EXCHANGE TRANSFUSION

DEFINITION

It is the procedure of removing the blood from the patient’s body and replacing it with donor blood.

INDICATION

Rh-isoimmunized baby.

Non immune hydrops fetalis

Sickle cell disease

Hyperammonemia

Neonatal hemochromatosis

hyperkalemia

Neonatal polycythemia.

Neonatal jaundice (serum bilirubin .20mg/dl).

DIC (disseminated intravascular coagulation).

Life threatening metabolic disorder.

Acute renal and hepatic failure.

Septicemia with sclerema.

Drug toxicity.

Partial exchange blood transfusion for chronic anemia.

Immediate exchange if jaundiced infant shows signs of acute bilirubin encephalopathy

CONTRAINDICATION

Hemodynamic instability

Sepsis

Severe hypocalcemia

ARTICLE

Fresh blood, 160-180ml/kg. This achieves a double volume exchange, which exchange as much as 87% of the baby’s blood. Single volume exchange only 63%.

Exchange transfusion set.

Normal saline.

Two three-way stopcocks.

Sterile syringes of 10ml, 20 ml.

Umbilical cannula 3.5fr, 4fr and 5fr or equivalents.

Bottles for taking blood samples.

Resuscitation equipment and drugs.

Personal protective equipment

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient.
Explain the procedure to parents/legal guardian and make sure that written consent is obtained.
Ensure that the blood is collected from the blood center..
Insert NG tube.
Keep the infant comfortable under radiant warmer.
Expose and immobilize baby on cross splint.
Fix cardiac monitor to monitor heart rate.
Make sure that the IV line is patent open the dressing pack and assist in the preliminary cleaning of umbilical stump.
Assist in scrubbing, gowning, and gloving.
Assist in cleaning umbilical cord and draping with sterile linen. Open the exchange transfusion set and leave it on sterile linen. Pour 100 ml of normal saline in the bowl small and add 1 ml Inj.Heparin to it Open and place 3 way stopcock(2), BG set(1), umbilical catheter or NG tube, cord tie and extra syringe (10cc), into sterile transfusion set
Countercheck the tag number and blood group and assist in connecting blood.
Assist during following steps: connecting three-way stopcock to BG set, 10cc syringe to umbilical catheter. Removing 10ml of umbilical blood and replacing with 10ml of fresh blood immediately, until calculated volume has been exchange sample of 10ml of blood from umbilical vein.
Send pre and post exchange sample of 10ml of blood from umbilical vein.
Record amount of blood withdrawn and replaced monitor heart rate, respiratory rate and condition of baby q1/2h. Remove all drapes and restart phototherapy. Replace equipment.
Document time of starting, duration, completion time, amount and type of blood exchanged, condition of baby during and after procedure, drugs given during procedure and samples sent to lab.
Monitor for vital signs, respiratory rate, heart rate and temperature every hour for next 6 hours watch for bleeding from procedure site.
Remove cord tie if there is no bleeding as per doctor’s order after 6 hours.

POST PROCEDURE CARE

à Phototherapy needs to be continued post exchange and reviewed with the results of the serum bilirubin (SBR) 2hours post-procedure. Further SBR levels at approximately 6 hours interval.

à Feeds are typically held for 3-24 hours after the procedure, depending on the infant’s stability. Observe for sighs of feed intolerance when feeding is recommended.

à Document how the infant tolerated the procedure and ensure the parents are informed.

COMPLICATION

· Catheter related complications: air embolism, thrombosis, hemorrhage.

· Hemodynamic: hypo or hypertension, intraventricular hemorrhage

· Hypo or hyper glycaemia

· Hypocalcemia, hyperkalemia, academia

NM2113 – ASSISTING IN EXCHANGE TRANSFUSION

ASSIST IN DOUBLE VOLUME EXCHANGE TRANSFUSION

DEFINITION

It is the procedure of removing the blood from the patient’s body and replacing it with donor blood.

INDICATION

Rh-isoimmunized baby.

Non immune hydrops fetalis

Sickle cell disease

Hyperammonemia

Neonatal hemochromatosis

hyperkalemia

Neonatal polycythemia.

Neonatal jaundice (serum bilirubin .20mg/dl).

DIC (disseminated intravascular coagulation).

Life threatening metabolic disorder.

Acute renal and hepatic failure.

Septicemia with sclerema.

Drug toxicity.

Partial exchange blood transfusion for chronic anemia.

Immediate exchange if jaundiced infant shows signs of acute bilirubin encephalopathy

CONTRAINDICATION

Hemodynamic instability

Sepsis

Severe hypocalcemia

ARTICLE

Fresh blood, 160-180ml/kg. This achieves a double volume exchange, which exchange as much as 87% of the baby’s blood. Single volume exchange only 63%.

Exchange transfusion set.

Normal saline.

Two three-way stopcocks.

Sterile syringes of 10ml, 20 ml.

Umbilical cannula 3.5fr, 4fr and 5fr or equivalents.

Bottles for taking blood samples.

Resuscitation equipment and drugs.

Personal protective equipment

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient.
Explain the procedure to parents/legal guardian and make sure that written consent is obtained.
Ensure that the blood is collected from the blood center..
Insert NG tube.
Keep the infant comfortable under radiant warmer.
Expose and immobilize baby on cross splint.
Fix cardiac monitor to monitor heart rate.
Make sure that the IV line is patent open the dressing pack and assist in the preliminary cleaning of umbilical stump.
Assist in scrubbing, gowning, and gloving.
Assist in cleaning umbilical cord and draping with sterile linen. Open the exchange transfusion set and leave it on sterile linen. Pour 100 ml of normal saline in the bowl small and add 1 ml Inj.Heparin to it Open and place 3 way stopcock(2), BG set(1), umbilical catheter or NG tube, cord tie and extra syringe (10cc), into sterile transfusion set
Countercheck the tag number and blood group and assist in connecting blood.
Assist during following steps: connecting three-way stopcock to BG set, 10cc syringe to umbilical catheter. Removing 10ml of umbilical blood and replacing with 10ml of fresh blood immediately, until calculated volume has been exchange sample of 10ml of blood from umbilical vein.
Send pre and post exchange sample of 10ml of blood from umbilical vein.
Record amount of blood withdrawn and replaced monitor heart rate, respiratory rate and condition of baby q1/2h. Remove all drapes and restart phototherapy. Replace equipment.
Document time of starting, duration, completion time, amount and type of blood exchanged, condition of baby during and after procedure, drugs given during procedure and samples sent to lab.
Monitor for vital signs, respiratory rate, heart rate and temperature every hour for next 6 hours watch for bleeding from procedure site.
Remove cord tie if there is no bleeding as per doctor’s order after 6 hours.

POST PROCEDURE CARE

à Phototherapy needs to be continued post exchange and reviewed with the results of the serum bilirubin (SBR) 2hours post-procedure. Further SBR levels at approximately 6 hours interval.

à Feeds are typically held for 3-24 hours after the procedure, depending on the infant’s stability. Observe for sighs of feed intolerance when feeding is recommended.

à Document how the infant tolerated the procedure and ensure the parents are informed.

COMPLICATION

· Catheter related complications: air embolism, thrombosis, hemorrhage.

· Hemodynamic: hypo or hypertension, intraventricular hemorrhage

· Hypo or hyper glycaemia

· Hypocalcemia, hyperkalemia, acidemia

NM2114 – ASSIST IN SUFACTANT THERAPY

DEFINITION

Pulmonary surfactant is a complex mixture of phospholipids and proteins that creates a cohesive surface layer over the alveoli which reduces surface tension and maintains alveolar stability therefore preventing atelectasis.

INDICATION

Neonates with clinical and radiographic evidence of RDS.

Neonates at risk of developing RDS (e.g. <32 weeks or low birth weight) with FiO₂ requirement >30% or increased work of breathing.

Neonates who are intubated, regardless of gestation, and requiring FiO2. >40% and who are at risk of RDS (Infant of diabetic mother).

Severe meconium aspiration syndrome with severe respiratory failure.

Pulmonary hemorrhage with clinical deterioration.

CONTRAINDICATION

Congenital anomalies incompatible with life

Perfusion failure status

Diffuse pulmonary hemorrhagic conditions

Congenital diaphragmatic hernia

EQUIPMENT

Multipara monitor

Transcutaneous CO2monitor (TCM) or end tidal CO2 monitor surfactant

Prescribed dose of surfactant (100 to 200 mg/kg of phospholipids)

Surfactant kit containing 4Fr20cm tube, syringe, needle free device or blunt needle OR

Alternative to surfactant kit: size 5Fr feeding tube, 5 ml compatible syringe (dose dependent), large gauge needle (18g, 19g or 20g).

Surfcath

Alcohol swab

Sterile towel or drape

Surgical blade no.22.

ET tube

Sterile straight scissors

Emergency equipment: neopuff and mask connected to oxygen, suction catheter.

Laryngoscope with blade.

Adhesive Tape

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient by hospital number
Explain the therapy to the parents or close relatives and obtain consent.
Identify the baby with hospital number and confirm with the medical record.
Record baseline observations: heart rate, respiration rate, oxygen saturation, TCO2/etCO2 and a blood gas if required.
Ensure and confirm correct position of the endotracheal tube via chest x-ray prior to giving surfactant.
Assist the physician throughout the procedure.
If neonate is not intubated, prepare the intubation and extubation set near the baby cot.
Check and prepare emergency equipment at bedside.
Determine the infant’s exact weight to ensure that the doses are accurate.
Evaluate perfusion assess the skin temperature and color.
Arrange the articles at the bedside.
Perform hand hygiene.
Open aseptic field and prepare sterile equipment and drop on to the aseptic field.
Ensure the bed is flat and place the neonate in supine position.
Cautiously disconnect the ETT from the ventilator.
Assist the doctor slowly in small aliquots over.2-5 minutes in coordination with the infant’s breathing if possible.
Once the surfactant is administered, assist to deliver positive pressure via neopuff and reconnects ETT to ventilator right after surfactant administration.
Hold the ETT for a few minutes to avoid the regurgitation.
Assess the drugs and drug delivery’s effectiveness, keep track of respirations, unusual sounds, and endotracheal tube placement and patency, and chest movements.
Do not suction for another 2 hours unless clinically necessary to give the drug time to work.
Monitor neonates vital signs closely every 10 minutes for 30 minutes then resume normal frequency of monitoring.
Clean surface, dispose the waste as per JMMCRI policy and perform hand hygiene.
Document all necessary information in the medical record.

POST PROCEDURE CARE

Ø The baby should remain on non-invasive respiratory support with continuous monitoring .prone positioning may be helpful if not contra-indicated.

Ø A reduction in the baby’s oxygen requirement in the following minutes to hour indicates that the procedure has been successful.

Ø Further doses of surfactant can be considered and the method of administration should be determined by the clinical condition of the baby.

COMPLICATION

Ø Pneumothorax

Ø Pulmonary hemorrhage

NM2115 – PERITONEAL DIALYSIS IN NEONATES

INTORDUCTION

Peritoneal dialysis is generally regarded as the optimal dialysis modality for neonates. Peritoneal dialysis allows for the removal of fluid and solutes while avoiding hemodynamic stability. This process uses baby’s peritoneum as a membrane across which fluids and dissolved substances are exchanged from blood.

TYPES

Continuous ambulatory peritoneal dialysis (CAPD).

Continuous cycling peritoneal dialysis (CCPD).

Continuous ambulatory peritoneal dialysis (CAPD).

Fluid exchanges are made manually.

Gravity makes the filling and draining process possible.

EQUIPMENT

Due to limited space in the peritoneal cavity in neonates, it is very difficult to place a rigid peritoneal catheter which is why alternatives are exploited such as

· Suction catheter

· Plastic catheter

· Peritoneal dialysis

· Angiocath

· Neonatal chest drain

· IV cannula

· Wallace catheter

· Cook 5F catheter

· Pendelburys cathter

· PPEs

· Dry gauze

· Syringe 10cc

· Local Anesthetic agent

· Straight scissor

· Surgical string

· 3- Way cannula

· Pulse oximetry

· PD solution

· Drain bag

INDICATION

· Anuria –Oliguria due to acute renal failure.

· Fluid overload causing heart failure/pulmonary edema

· Electrolyte abnormalities unresponsive to medical management (hyperkalemia≥8mEq/L, hyponatremia≤120mEq/L).

· Severe metabolic acidosis resistant to NaHCO₃and supportive therapies (sodium bicarbonate concentration ≤12mEq/L)

· Toxic metabolic accumulation exogenously /due to inborn errors of metabolism.

CONTRA-INDICATION

· Abdominal wall defect such as omphalocele gastrochisis

· Diaphragmatic hernia

· Bladder extrophy

· Bleeding diathesis

· Abdominal malignancy

· Obliterated peritoneal cavity

ACUTE PERITONEAL DIALYSIS

o Duration of dialysis is 48-72 hours.

o Dialysate composed of water, osmotic agents, electrolytes and minerals

o Exchange volume (initial 10ml/kg, can increase up to 35-40ml/kg).

o Inflow time (10-15 minutes) and outflow drain time is 20-30 minutes

o Dwell time (30-90 minute)

o Number of exchanges (24/day, 48-72 exchanges with each one hour)

o Heparin, insulin and potassium are dialysate additives.

o Monitoring fluid and electrolytes balance

§ Blood sugar in every 4-6 hourly

§ Serum electrolytes every 6-12 hourly

§ Serum creatinine every 24 ^th hourly

o Monitor infant’s weight every 12-24 hourly.

INSERTION

· Common site midline below the umbilicus, right or low lower quadrant of the umbilicus.

· Pig tail and straight rigid catheters without cuffs have been preferred or any catheters.

· Bladder should be emptied.

PROCEDURE
NURSING ACTION	RATIONALE
Identify the patient with hospital number and obtain the informed consent after explaining the procedure.
Disinfect the skin
Subcutaneous administration of local anesthetic (1% xylocaine)
Place the IV cannula or catheter in the peritoneal cavity in the left part of umbilical region using the blind technique.
Tape the soft plastic extension of the catheter to the skin. Connect the catheter to a peritoneal dialysis delivery system by a 3-way cannula.
Apply adhesive tape at the insertion site
A three way cannula was fixed to the cannula. One end was attached to the baby, a bag containing the dialysis liquid The other was attached to a drainage bag
Initiate the dialysis with 1.5% glucose, fill volume 10ml/kg of dialysis solution, dwell time 10 minute, drain time-10 minute
Prophylactic antibiotic may be given.
Monitor for any complication
Discard the waste as per JMMCRI protocol
Perform hand hygiene.
Document all relevant information in the medical record.

COMPLICATIONS

· Peritonitis

· Fluid leakage

· Hyperglycemia

NM2116a - IMMUNIZATION

Immunization is a proven tool for controlling and even eradicating disease.

The antigens used for immunization are both viral and bacterial. They have been changed to eliminate or modify the pathogenicity of microbiologic agent.

Immunity

The resistance offered by the host to the harmful effect of pathogenic microbial infection is called immunity. Immunity is of two types,

Innate immunity

Acquired immunity

Vaccines

Active immunizing agents are vaccine. A vaccine is an immune biological substance designed to produce specific protection against a given disease. It stimulates production of protects antibodies.

Types of Vaccines

Live attenuated- live vaccines are prepared from the live organisms which have lost their capacity to induce full blown disease.

Inactivated or killed vaccines- these vaccines consist of suspension of killed or inactivated organism.

Toxoids-certain organism like diphtheria bacilli and tetanus bacilli produce exo-toxins which are de-toxicated and used in preparation of vaccines.

Cellular fractions-some vaccines are prepared from extracted cellular fractions. For example meningococcal vaccine produced from polysaccharide cell wall of antigen.

Combination vaccines- if more than one kind of immunizing agent is included in the vaccine, it is called as combination vaccine. For e.g.:- DPT vaccine, DT vaccine.

Type of Vaccine

TYPE OF VACCINE	VACCINE AGAINST BACTERIA	VACCINE AGAINST VIRUS
LIVE ATTENUATED VACCINE	BCG	ORAL POLIO VACCINE
	CHOLERA	MUMPS
	TYPHOID ORAL	MEASLES
		RUBELLA
		ROTAVIRUS
INACTIVATED OR KILLED VACCINE	DIPHTHERIA	RABIES
	PERTUSSIS	POLIO
	PNEUMOCOCCAL	H.INFLUNZA
	TYPHOID	HEPATITIS B
		MEASLES
TOXOIDS	DIPHTHERIA
	TETANUS

Barriers to Vaccination

Safety concerns

Concerns for the pain inflicted on the child.

Lack of awareness regarding vaccine preventable disease

High impact of negative media information.

DIFFERENCE BETWEEN IMMUNOGLOBULIN AND VACCINE
Vaccines are active immunizing agent.	Immunoglobulin is passive immunization.
Vaccines are made from live or killed organism	Immunoglobulin are obtained from human serum or from animals

General Instruction

· Vaccination at birth means as early as possible within 24-72 hours after birth at or at least not later than 1 week after birth.

· The recommended age in weeks/ months/years mean completed weeks/months/years.

· Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible.

· The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccine.

· The minimum interval between two doses of inactivated vaccines is usually 4 weeks (exception rabies)

· Vaccine doses administered up to 4 days before the minimum interval or age can be counted as valid (exception rabies). If the vaccine is administered >5 days before minimum period, it is counted as invalid dose.

· Any number of antigens can be given on the same day.

· Different vaccines should not be mixed in the same syringe unless specifically licensed and labeled for such use.

· Patient should be observed for an allergic reaction (anaphylaxis) for 15-20 minutes after receiving immunizations.

· When necessary, two vaccines can be given in the same limb (1-2 inches apart) at a single visit

· The anterolateral aspect of thigh is the preferred site for two simultaneous intramuscular injections because of its greater muscle mass.

· Gently pull back the syringe before the injection is given, if blood appears after negative pressure, the needle should be withdrawn and another site should be selected using a new needle.

· Previous immunizations with a dose that was less than the standard dose or one administered by a nonstandard route.

· Changing needle between drawing vaccine into the syringes and injecting it into is mandatory.

· The storage temperature of refrigerator for vaccine is 2⁰C -8⁰C.

Injection site, type of needle, and technique.
Age	Site	Type of needle	Comments
Intramuscular injections (needle should enter at a 90⁰angle)
Preterm and neonates	Antero-lateral thigh(junction of middle and lower third)	22-25 gauge, 5/8 inch	Skin should be stretched between thumb and forefinger.
Infants (1 to <12 months).	Antero-lateral thigh	22-25 gauge, 1 inch.	Bunch the skin, subcutaneous tissue, and muscle to prevent striking the bone.
Toddlers and older children(12 months to 10 years)	Antero-lateral thigh	22-25 gauge, 5/8 inch	Skin should be stretched between thumb and fore finger.
Toddlers and older children(12 months to 10 years)	Antero-lateral thigh	22-25 gauge,1 inch	Bunch the skin, subcutaneous tissue and muscle.
Adolescent s and adults(11 years onward)	Deltoid or antero-lateral thigh	<60kg,1 inch >60kg,1.5 inch
Subcutaneous injections ( needle should enter at 45⁰ to the skin)
Infants	Thigh	22-25 gauge, 5/8inch
>12 months	Outer triceps	22-25 gauge, 5/8 inch
Intra-dermal injections
All ages	Left deltoid	26/27gauge, 0.5inch	A 5mm wheel should be raised

Cold Chain

It is a system of storage and transport of vaccines at optimum temperature (2-8⁰C) from manufacturer to the site of vaccination this cold chain is needed because vaccines are sensitive to heat and they may lose their potency if not stored and transported at optimum temperature.

Oral polio vaccine requiring storage at -20⁰C.

COLD CHAIN STORAGE
Vaccines to be stored in freezer	OPV MEASLES
Vaccines to be stored in cold part of refrigerator but not freezer.	TYPHOID DPT DT BCG TT
Vaccines that can be kept at room temperature	TT

Vaccine Vial Monitor

A vaccine vial monitor is a label containing a heat sensitive material, which is placed on a vaccine vial to register cumulative heat exposure over time.

A VVM enables the health care giver to know whether vaccine has been damaged by exposure to heat.

The VVM is a circle with a small square inside it, which is lighter in color at the starting point.

The combined effect of time and temperature causes the inner square of the VVM to darken gradually.

The color change is irreversible.

If the inner square is lighter than the outer ring, the vaccine can be used, whereas if inner square is matches has darker color than outer ring, then the vaccine should be discarded.

Vaccine schedule under routine immunization
Vaccine	When to give	Dose	Route	Site
BCG	At birth or as early as possible till one year of age	0.1ml	Intradermal	Left upper arm
Hepatitis B	At birth or as early as possible	0.5m	Intramuscular	Anterolateral side of mid thigh
OPV zero dose	At birth or as possible within the first 15 days	2 drops	Oral	Oral
OPV 1,2 &3	At 6 weeks, 10 weeks & 14 weeks	2 drops	Oral	Oral
Pentavalent 1,2 &3	At 6 weeks, 10 weeks & 14 weeks	0.5ml	Intramuscular	Anterolateral side of midthigh.
Fractional IPV	At 6 &14 weeks	0.1ml	Intradermal	Upper arm -right
Rotavirus	At 6 weeks,10 weeks & 14 weeks	5 drops	Oral	Oral
Pneumococcal conjugated vaccine	At 6 weeks and 14 weeks, at 9 completed booster	0.5ml	Intramuscular	Antero-lateral side of midthigh
Measles Rubella 1^st dose	9 completed months -12 months	0.5ml	Subcutaneous	Right upper arm
IPV booster	9 completed months	0.1ml	Intradermal	Right upper arm
JE 1st dose	9 completed months	0.5ml	Subcutaneous	Left upper arm
DPT booster	16-24 months	0.5ml	Intramuscular	Anterolateral Side of midthigh
OPV booster	16-24 months	2 drops	Oral	Oral
Measles Rubella 2^nd dose	16-24 months	0.5ml	Subcutaneous	Right upper arm
Rubella	Adolescent girls	0.5ml	Subcutaneous	Right upper arm
JE 2^nddose	16-24 months with DPT/OPV booster	0.5ml	Subcutaneous	Left upper arm
DPT booster 2	5-7 years	0.5ml	Intramuscular	Upper arm
	10 years & 16 years	0.5ml	Intramuscular	Upper arm
Vitamin A	The second to 9^th dose of vitamin a can be administered to children 1-5 years old during biannual rounds.

STORAGE OF VACCINE IN REFRIGERATOR

BCG Vaccine

The vaccine contains 0.1-0.4 million live viable bacilli per dose.

It is supplied as a lyophilized (freeze-dried) preparation in vacuum-sealed, multi-dose, amour colored ampoules or 2ml vials with normal saline as diluents.

As the vaccine contains no preservative, bacterial contamination and consequent toxic shock syndrome, if kept for long after reconstitution. The reconstituted vaccine should be stored at 2-8⁰C, protected from light, and discarded within 4-6 hours of reconstitution.

Correct intradermal administration can be verified by a bleb of 5mm formation.

The injected site usually shows no visible change for several days. Subsequently a papule develops after 2-3 weeks, which increase to a size of 4-8mm by the end of 5-6 weeks. This papule often heals with ulceration and results in a scar after 6-12 weeks.

The ulcer at vaccination site may persist for a few weeks before formation of the final score.

No treatment is required for this condition.

There is evidence that BCG vaccine can be safely administered with diphtheria-pertussis-tetanus, polio, hepatitis B, haemophilus influenza type B (Hib) and measles and rubella

Vaccine.

POLIO Vaccine

Oral polio vaccine is composed of live attenuated polio viruses derived of their wild polio virus strains by passage in non-human cells to obtain the three vaccine strain (Sabin).

Attenuation reduces its neuro-virulence and transmissibility.

Oral polio vaccine is administered as two drops (~0.1ml), directly into the mouth. It is highly heat sensitive and must be kept frozen for long-term storage, or after thawing, at temperature between 2⁰C and 8⁰C for a maximum of six months.

Sequential of IPV followed by OPV reduces or prevents Vaccine associated paralytic poliomyelitis (VAPP) while maintaining the high levels of intestinal mucosal immunity conferred by OPV.

HEPATITIS B Vaccine

The protective efficacy of hepatitis B vaccination is related to the induction of antibody to hepatitis B surface antigen (anti Hbs) antibodies, but also involves the induction of memory Tcells.

An antibody HBs concentration of more than 10MIU/L measured 1-3 months after administration of the last dose of the primary vaccination series is considered a reliable correlate of protection against Hepatitis B

The dose in children and adolescents (aged less than 18 years) 0.5ml/10 μg and in those 18 years and older is 1 ml/20 μg.

The vaccine is highly immunogenic and sero-conversion rates are greater than 90% after a three-dose schedule.

Infants who did not receive a birth dose should receive three doses of a hepatitis B containing vaccine starting as soon as feasible.

The ideal minimum interval between dose 1 and dose 2 is 4 weeks, and between 2nd and 3rd dose is 8 weeks. Ideally the final dose in hepatitis B vaccine series should be administered no earlier than 24 weeks and at least 16 weeks after the first dose, whichever is later.

DIPHTHERIA, TETANUS, WHOLE CELL PERTUSSIS Vaccines

Popularly known as triple antigen, DTwP is composed of tetanus and diphtheria toxoids as well as killed whole cell pertussis (wP) bacilli absorbed on insoluble aluminum salts which acts adjuvant.

The vaccine need to be stored at 2-8⁰C.these vaccine should never froze, and if frozen accidently, should be discarded.

The immunogenicity (protective titer for diphtheria >0.1IU/ml and for tetanus >0.1IU/ml) and effectiveness against diphtheria or tetanus of three doses of the vaccine exceeds 95%.

NM2201a - CHEST PHYSIOTHERAPY

DEFINITION

Method of facilitating respiratory function by removing thick, tenacious secretions from the respiratory system using techniques of percussion, vibration and postural drainage

PURPOSE

· Improve respiratory function

· Prevent collapse of the lung

· To remove tenacious secretions from bronchial walls in conditions like bronchiectasis and chronic bronchitis.

INDICATIONS

· Patients who bring out copious sputum

· Patients who are at risk of atelectasis

ARTICLES

· Pillows

· Stethoscope

· Sputum cup with disinfectant

· Paper tissues

· Adjustable bed

· Kidney tray

CONTRA-INDICATIONS

· Undrained lung abscess

· Pregnancy

· Lung tumor

· Pneumothorax

· Diseases of chest wall

· Lung hemorrhage/hemoptysis

· Tuberculosis

· Osteoporosis

· Increased intracranial pressure

· Painful chest conditions, e.g. pleural effusion

PROCEDURE

NURSING ACTION	RATIONALE
Identify patient and check instruction of physician and nursing care plan	Ensures that right procedure is done on the right patient.
Explain procedure to patient and check time of last meal	Reassures patient and promotes cooperation. Postural drainage should be avoided immediately after meal time as it can induce vomiting.
Wash hands and dry	Reduces transmission of microorganisms
Instruct patient to perform diaphragmatic breathing. Place one hand on the chest and other on the abdomen below the rib cage. Breathe slowly in through the nose drawing the breath down toward the stomach. Pause in between inhale and exhale. Release the air through the pursed lips.	This method of breathing helps patient to relax and widens airways
Position patient in prescribed postural drainage position, after consulting with physician	Position should be selected according to the area of lung that is to be drained.
Cover area with towel	Reduces discomfort to patient
Percussion Clap with cupped hands over chest wall for 1 to 2 minutes in each lung area. Percuss from Lower ribs to shoulder on the back Lower ribs to top of chest in front Avoid clapping over spine, liver, kidney, spleen , breast bone (sternum), clavicle, or sternum	Percussion helps in dislodging mucous plugs and mobilizes secretions into main stem bronchi and trachea. The air trapped under cupped hand sets up vibration through chest wall freeing secretions. Percussion over these areas may cause injuries
Vibration Remove towel and place hand, palm down on chest area to be drained with one hand over the other and fingers together or place hands side by side.
Instruct patient to inhale deeply and exhale slowly through pursed lips and perform abdominal breathing.
Tense all the muscles of the hand and arm and vibrate the hand especially palm heels with moderate pressure during exhalation	Vibration frees the mucus from bronchial wall
Stop vibration and relieve pressure on inspiration.	Pressure applied to chest wall inhibits chest expansion during inspiration
Vibrate for 5 exhalations over each lung area which is affected. After 3-4 vibrations, encourage patient to cough/huff and expectorate sputum into sputum cup.	Cuffing or huffing aids in the movement and expulsion of secretion from the respiratory tract.
Allow patient to rest for several minutes.
Auscultate with stethoscope for change in breath sounds.	Presence of crackles/ ronchi indicate mucus present in bronchi
Repeat percussion and vibration cycles according to patient’s tolerance and clinical condition, usually for 10-15 minutes
Perform hand hygiene.	Reduces risk of transfer of microorganisms.
Assist patient to comfortable position.
Assist with oral hygiene.	Promotes comfort by removing the bad taste of sputum in the mouth
Document areas percussed, postural drainage positions and the position of the patient at the end of the therapy in the medical record.	Enables communication between staff members

COMPLICATIONS

· Position related hypoxia

· Aspiration of freed secretions

NOTES

· Check pulse and respiratory rate before and after the procedure

· Auscultate chest before and after the procedure

· Inform physician the positions not tolerated by the patient

· Give priority to patient’s comfort before positioning

· Pocket mask can also be used instead of cupped hand

· Percuss back and forth or in circular motion, not continuously in circular motion

· Use caution over breast area.

· If significant change in the vitals observed during the procedure, inform the physician after repositioning the patient.

· Encourage coughing throughout the procedure.

· Do not leave the patient unattended.

· Perform chest physiotherapy one hour before meals or 1-3 hours after meals.

· Administer bronchodilator/metered dose inhaler if ordered or nebulizer15 minutes before procedure.

· Suctioning will be helpful for the removal sputum after chest physiotherapy.

· Observe patient during treatment for tolerance-like breathing pattern cyanosis, etc.

· Splint incision area, so that pain is tolerable.

· Administer pain medications if ordered, 15 to 20 minutes before procedure.

· Chest physiotherapy can be done two or more times as per the doctor’s advice.

· Stop procedure if there is tachycardia, fall in BP, palpitation, dyspnea or chest pain which indicates hypoxemia.

Ø For rib fracture patients a vibrator can be used

Ø For spinal injury spirometer and vibrator can be used.

Pediatric variations

For infants, a soft circular mask or a percussion cup is used for percussing small areas.

Maximum of three fingers can be used for giving physiotherapy.

A popping, hollow sound should be the result of and not a slapping sound.

The procedure is done over the rib cage only and should be painless.

NM2202a - POSTURAL DRAINAGE

DEFINITION

Postural drainage is the gravitational clearance of secretions from a specific bronchial segments by using one or more of ten different positions.

Each position drains a specific corresponding section of the tracheobronchial tree, either from the upper, middle or lower lung field into the trachea.

Areas are selected for drainage based on:

· Knowledge of patient’s condition, and disease process.

· Physical assessment of the chest.

· Chest X-ray examination results.

CONTRA-INDICATIONS

ARTICLES

A comfortable surface, that can be slanted such as hospital beds in trendlenburg position or tilt table and chair for draining upper lobe areas.

One to four pillows, depending on patient’s posture and comfort.

A glass with water.

Tissues and paper bag.

Sputum cup.

POSITION FOR DRAINING DIFFERENT AREAS OF LUNGS

LEFT AND RIGHT UPPER LOBE ANTERIOR APICAL BRONCHI:

· Have patient sit in chair leaning back.

· Percuss with cupped hands and vibrate with heels of hands at shoulders and with fingers over collarbone.

· Both sides can be done at the same time.

· Note body posture and arm position of nurse.

· Nurse’s back is kept straight and elbows and knees are slightly flexed.

LEFT AND RIGHT UPPER LOBE POSTERIOR APICAL BRONCHI:

· Have patient sit in chair leaning forward on pillow or cardiac table.

· Percuss and vibrate with hands on either side of the upper spine, can do both sides at the same time.

RIGHT AND LEFT ANTERIOR UPPER LOBE BRONCHI:

· Have patient lie flat on back with small pillow under knees.

· Percuss and vibrate just below the clavicle on either side of sternum.

LEFT UPPER LOBE LINGULAR BRONCHUS:

· Have patient lie on right side with arm over head in trendelenburg position with foot of bed raised 30⁰. Place pillow behind back and roll patient one-fourth on to pillow.

· Percuss and vibrate lateral to left nipple below axilla.

RIGHT MIDDLE LOBE BRONCHUS:

· Have patient lie on left side, raise foot of bed to 30⁰.Place pillow behind back and roll patient one-fourth turned on to pillow.

· Percuss and vibrate area of right nipple below axilla.

LEFT AND RIGHT ANTERIOR LOWER LOBE BRONCHI:

· Have patient lie on back in Trendelenburg position, with foot of bed elevated 45-50⁰.Have knees bent on pillow.

· Percuss and vibrate over lower anterior ribs on both sides.

RIGHT LOWER LOBE LATERAL BRONCHUS:

· Have patient lie on left side in trendelenburg position, with foot of bed raised 45-50⁰.

· Percuss and vibrate right side of the chest below scapula posterior to midaxillary line.

LEFT LOWER LOBE LATERAL BRONCHUS:

· Have patient lie on right side in trendelenburg

· Percuss and vibrate left side of the chest below scapula posterior to midaxillary line.

RIGHT AND LEFT LOWER LOBE SUPERIOR BRONCHI:

· Have patient lie flat on stomach with pillow under stomach.

· Percuss and vibrate below scapula on either side of spine.

LEFT AND RIGHT POSTERIOR BASAL BRONCHI:

Have patient lie on stomach in trendelenburg position with foot of bed elevated 40-50⁰.

Percuss and vibrate over posterior ribs on either side of spine.

PROCEDURE

NURSING ACTION	RATIONALE
Identify patient and check physician’s order for specific instructions for postural drainage	Perform correct procedure for the right patient
Assess for possible impairment of airway clearance.	Certain circumstances, disease process, and conditions place patient at risk for impaired airway clearance.
Identify signs and symptoms that indicate need to perform postural drainage.
Identify which bronchial segments needs to be drained by reviewing chest X-ray reports. Auscultate over all lung fields for crackles, wheezes and gurgles, palpate over all lung fields for crepitus, fremitus and chest expansion	Area of lung congestion and postures for drainage will vary depending on disease process, patient condition and patient problem.
Wash hands.	Reduces transmission of micro-organism
Select congested areas to be drained based on assessment of all lung field, clinical data and chest X-ray data.	To be effective treatment must be individualized to treat specific areas involved.
Place patient in position to drain congested areas Area selected may vary from patient to patient. Help patient assume position as needed. Teach patient correct posture and arm and leg positioning, place pillows for support and comfort.	To be effective treatment must be individualized to treat specific areas involved.
Have patient maintain posture for 10 to 15 minutes.	In adults, draining each area take time.
During 10 to 15 minutes of drainage in each posture, perform chest percussion and vibration over area being drained.	These maneuvers provide mechanical forces that aid in mobilization of airway secretions.
After 10 to 15 minutes of drainage in first posture, have patient sit up and cough. Save expectorated secretions in clear container. If patient cannot cough suctioning to be performed.	Secretions mobilized into central airways should be removed by coughing or suctioning before placing patient into next drainage position. Coughing is most effective when patient is sitting up and leaning forward.
Have patient rest briefly is necessary	Short rest periods between postures can prevent fatigue and help patient for better tolerance to therapy.
Have patient take sips of water	Keeping mouth moist aids in expectoration of secretions.
Repeat procedure until all congested areas selected have been drained. Each treatment should not exceed 20 to 30 minutes.	Postural drainage is used only to drain areas involved and is based on individual assessment
Wash hands.	Reduce transmission of micro-organisms
Record in medical record , baseline data and post therapy assessment of chest, frequency and duration of treatment, postures used and bronchial segments drained, cough effectiveness	Helps to evaluate outcomes and need for changes in therapy.

SPECIAL CONSIDERATION

· Provide inhalation using bronchodilator 20 minutes before postural drainage for patients at risk of bronchospasm.

· In severe hemoptysis, stop therapy, remain calm, and stay with patient. Request assistance and keep patient comfortable, warm and quiet.

Best times for treatment are:

· In the morning before breakfast, when patient can clear secretions that accumulate overnight.

· One hour before bed time, so lungs are clear before sleeping and patients has time after treatment to cough up any mobilized secretions.

· If patient’s condition is acute, frequent treatments are tolerated best.

· If patient is receiving- inhaled bronchodilators or aerosol therapy, postural drainage should be done after 20 minutes.

· The procedure should be discontinued if tachycardia, palpitation, dyspnea or chest pain occur. These symptoms may indicate hypoxemia

Do not perform postural drainage immediately taking food.

NM2301 - DEATH CARE

MEANING

Care of body within 45 minutes following declaration of death by doctor.

PURPOSE

a) Maintain normal body alignment.

b) Prepare the body for transport to mortuary/residence.

c) Ensure privacy and dignity.

d) Honoring the spiritual and cultural belief of deceased and family.

e) To comply with legal requirements.

General instructions

a. Perform the procedures with dignity and respect.

b. Allow the relatives to view and identify the body.

c. The body is generally placed in a supine position with pillow under the head.

d. The head is slightly elevated to prevent post mortem hypostasis of blood which could discolor the face.

e. The body should appear clean, comfortable and peaceful.

f. Dentures if present should be inserted immediately after death.

g. If ankles and thumbs are to be tied together, they should be well padded to prevent bruising.

h. Prevent leakage from the oral cavity and tracheostomy site by suctioning, positioning, suturing and tight dressing.

i. The form no.2 (death report) is signed by physician and then sent to concerned office within 24hours.

j. Form no.4 or medical certificate of cause of death shall be duly filled by the duty doctor and lower portion of the form shall be detached and handed over to the next to kin (relative) of the deceased.

k. Be sensitive to other hospitalized patients/relatives while transporting the body.

l. Hand over the body to next to kin.

EQUIPMENT

§ Straight Artery forceps

§ Straight scissors

§ Gauze

§ Gloves

§ Bandage

§ Cotton

§ Suction catheter

§ Wet wipes

§ Suturing set (if needed)

§ 2 Long white cloth (2-3 meters)/ 2 bed sheets

§ Patient’s clothing (if needed)

PROCEDURE

§ Notify the time of declaration of death in the medical record.

§ Check orders for any specimen to be collected.

§ Provide privacy.

§ Ask for any special requests from family (shaving, a special gown, etc.)

§ Find out what the patient’s wishes regarding organ and tissue donation.

§ Treat the patient and family with sensitivity, dignity and respect.

§ Disconnect all tubing gently and seal wounds with clean gauze and adhesive.

§ Remove all valuables from patient’s body and hand it over to close relatives and obtain acknowledgement.

§ Hand over the belongings to the next to kin and document in the medical record. Specify the color of metal/mineral and obtain acknowledgement.

§ Before rigor mortis develops, position the body in normal alignment and close the eyes.

§ Replace the dentures to patient’s body.

§ Clean the body thoroughly using wet wipes and gauze pad using a straight artery and remove secretion, discharge and bloodstains.

§ Dress the patient with clothing provided by the family

§ Place the body in supine position with head on small pillow, arms by the side, palms down or hands folded on abdomen as per religious rituals.

§ Plug orifices (nose, mouth, vagina and rectum) with cotton.

§ Straighten the legs, bring feet together to tie the big toe together.

§ Comb and tie the hair

§ Tie toe tag on the right big toe.

§ Cover the body with clean sheet. Wrap it in clean sheet and taped tightly to ensure it can be moved safe.

§ Apply the chest label on the outer cloth sheet over the chest.

§ Do not bend the sheet too tightly as this can cause disfigurement.

§ If the body is to be kept in mortuary, follow the hospital policies.

§ Allow the family members (two close relatives) to view the body.

§ Within one hour, handover the body to next to kin, after settlement of the bill. If bill settlement takes more than one hour, keep the body in mortuary.

§ Dead body should not remain in the Ward/Room/ICU/EMD beyond one hour.

§ If delayed beyond one hour, duly filled mortuary request form shall be given to Emergency PRC by ANM/ Housekeeping staff. Dead body will be shifted to mortuary by Ambulance. Inform Mr. Robin (8 am – 5 pm) & to console (dial 9) for ambulance in remaining hours.

§ Obtain the duly filled form no.2 or death report from the next to kin (relatives) and hand it over to the concerned nurse.

§ Accompany the deceased from ward / ICU to an ambulance or mortuary.

§ Document in Death and MLC intimation register.

§ Clean the patient’s bed and unit using soap solution and 0.1% of sodium hypochlorite in infected cases

Notes

Ø If requested by the relatives, make provision for performing religious rituals soon after death.

MEDICO-LEGAL CASES (death)

Any suspicious circumstances is felt by the consultant, can be referred as medico-legal cases

HANDLING MEDICO-LEGAL CASES

Medico legal cases includes but not limited to

v All cases of unnatural injuries

v All vehicular, factory, riot or other unnatural accident cases

v Cases of unconsciousness where its cause is not clear

v All cases of suspected or evident poisoning or intoxication

v Cases brought dead with improper history creating suspicion of an offence

v Cases of suspected self-inflation of injuries or attempted suicide

v All cases of accidents, burns, assaults, alleged suicide/homicide, road traffic accidents, drowning, sexual assault/abuse etc.

Responsible persons

CMO

Duty doctor

Assigned Staff nurse

EMD PRC

MLC staff

Front office staff

PROCEDURE

o Note the time and date of death. Death should be declared by consultant doctor/admitting physician.

o Death care should not be given. Tubes and lines can be removed.

o Inform EMD PRC(24hrs) and MLC office (7.30 am to 7.30 pm)

o Body should kept in hospital mortuary (freezer) under safe custody.

o Duly filled medical record should be handed over to MLC office for police intimation.

Dead on arrival (Brought dead cases)

· Death is to be confirmed by medical practitioner.

· Enter into brought death register.

· No death care to be given, do not remove the clothing nor clean the body. Keep the body in anatomical position

· All brought dead cases are medico-legal. If the doctor is very sure that the death was natural he can release the body, but the responsibility vests with the doctor himself.

NM2404 – ASSISTING IN ECMO

EXTRACORPOREAL MEMEBRANE OXYGENATION (ECMO)

Extracorporeal membrane oxygenation system, a life support system, is an invaluable tool to treat adult and children with life threatening cardiac and pulmonary dysfunction that is refractory to the conventional management or when cardiopulmonary resuscitation (CPR) measures are not successful in achieving the return of spontaneous circulation.

An ECMO machine consists of a pump with an oxygenator that replaces the function of the heart and lung, respectively. The primary purpose of ECMO is performed by replacing the function of the heart and lungs, which gives these organs considerable time to recover.

Veno-venous ECMO (VV ECMO) provides respiratory support, whereas veno-arterial ECMO (VA ECMO) provides cardiorespiratory support.

Extracorporeal membrane oxygenation consists of a circuit where blood is drained through a catheter from the venous vascular system, circulated in a pump outside a body, and reinfused into the other venous or arterial vascular system depending on the ECMO circuit for circulation in the body.

Cannulas made of plastic tubes are placed in veins or arteries in the groins, neck or chest. A catheter withdraws blood from the cannula through veins that consists of high carbon dioxide and low oxygen count. Deoxygenated blood extracted from the venous catheter gets transferred to the oxygenator with the help of a pump.an oxygenator works as an artificial lung that maintains the CO₂ extraction and oxygenation flow rate. Air and oxygen flow through the hollow fibers in the oxygenator. As the blood passes through tiny fibers, oxygen leaves the fibers and replaces carbon dioxide in the red blood cells (RBCs).CO₂then enters the fiber and is removed in the exhaust gas. Oxygenated blood is delivered through the catheter back to the patient.

INDICATION

· Age <70 yrs

· Cardiopulmonary arrest to first CPR <5 minutes

· Witnessed arrest

· Ventricular fibrillation (VF) or paroxysmal ventricular tachycardia or pulseless electrical activity as initial cardiac rhythm.

· Recurrent VF or intermittent ROSC

· Absence of comorbidities like end-stage heart failure / chronic obstructive pulmonary disease /liver failure/ end-stage renal failure or terminal irreversible illness.

· No known aortic valve competence.

CONTRAINDICATION

· Unwitnessed cardiac arrest

· Prolonged CPR without adequate tissue perfusion

· Not a transplant or VAD support candidate

· Unrepaired aortic dissection

· Severe aortic regurgitation

· Unrecoverable severe brain injury

· Disseminated malignancy

· Severe organ dysfunction, for example, emphysema/ cirrhosis/ renal failure

· Peripheral vascular disease in cases of peripheral VA ECMO

· Lethal chromosomal abnormalities

· Pulmonary hypertension (mean pulmonary artery pressure>50 mmHg) or cardiogenic failure: VV ECMO is contraindicated.

· Obesity

· Advanced age

· Pre-existing chronic illness with long term poor prognosis

· Prolonged mechanical ventilation > 14 days

PREPARATION

Ø Identify the patient by hospital number

Ø Insert the cannula

Ø Connect to the circuit (removal of all air from the circuit).

Ø Check for gases

Ø Make sure that there are no air bubbles in the circuit, membrane, or connections.

Ø Connect sweep gas flow to the oxygenator and start at 3-4 L/min

Ø Increase rotation per minute (RPM) to generate adequate positive pressure in the return limb of the circuit.

Ø Clamps on the circuit are removed and ensure the blood flow of ECMO.

Ø Increase RPM to achieve 3-4 L/min ECMO blood flow.

Ø Mechanical chest compressions are disconnected if in cardiac arrest.

POST ECMO PLACEMENT CARE

Monitor ECMO circuit blood flow. A decrease in flow gives an indication of possible intra-abdominal or thoracic hemorrhage, cardiac tamponade, or left ventricular distension with pulmonary congestion.

Monitor for refractory arrhythmias. Arrange the necessary for electric cardioversion.

Mechanical ventilation with positive end-expiratory pressure of >10cm H₂O is suggested to decrease the LV afterload and prevent and treat pulmonary edema. The mixture of ECMO gas with air and oxygen prevents hyperoxia. Targeted temperature management with heat exchanger, 33 to 36 for initial 24 hours followed by gradual rewarming to 37⁰C is suggested. Peak inflation pressure20 to 25 cm H2O, FiO2<0.5, respiratory rate 4-8 breaths/minute, and tidal volume of <100mL have been suggested.

To prevent limb ischemia in the case of VA ECMO distal perfusion cannula should be inserted on the side of the arterial cannulation.

Cardiac arrests should be treated with cardiac catheterization post ECMO cannulation.

Imaging with CT brain, CT pulmonary angiography, CT abdomen/pelvis is recommended post cardiac arrest if etiology is unclear or falling ECMO blood flow. Early echocardiography to assess ventricular function and valvular assessment.

Intra-aortic balloon pump (IABP) is considered a first choice when mechanical circulatory support is indicated. IABP increases pulsality, decreases the ventricular afterload, and improves coronary perfusion.

WEANING OF ECMO

In the case of VV-ECMO assessment of native respiratory function performed by altering the gas flow through the ECMO circuit 50 to 65%. Usually, recovery of pulmonary functions takes around 1 to 3 weeks. Signs of recovery or pulmonary function can be a progressive increase in SaO2 greater than SvO2, improvement in chest x-ray or improving lung compliance.

Weaning is considered when the gas exchange can be maintained with low FiO2 (<30%); <2L/MIN fresh gas flow rates into the circuit at the respiratory rate of <25 breaths/minute and <15cm H2O of PEEP.

In the case of VA ECMO, once the etiology of cardiac arrest is addressed and native cardiac function is returned, weaning of ECMO can be planned.

Cardiac function assessment is performed by reducing flows in the ECMO circuit, changes to the ventilator and oxygen flow settings, and increasing heparin dose requirement to prevent thrombosis at low ECMO flow rates. To assess cardiac function and response to reduced flow rates, a trans-esophageal echocardiogram (TEE) is used.

Inotropic weaning is usually started several hours before the weaning, reduction in-circuit flow should be 1 to 2 L/min.

After 1 or 2 hours of minimal support or without any support, if the patient is stable, they can be decannulated in a surgical setting.

There is no definite timeline for weaning and decannulation, but typically, 3 to 4 days of ECMO support is usually seen.

NURSING MANAGEMENT

Maintenance of intravascular volume and systemic perfusion is essential.

Urine output, central venous pressure, body weight and physical signs of perfusion were used to assess the volume status.

Inotropic support such as epinephrine, norepinephrine, or dopamine can be considered.

Patient on ECMO should have daily radiographs, endotracheal suctioning every 4 to 6 hours depending on the secretions, frequent posture changes, and flexible bronchoscopy when required.

Oliguric phase: For initial 24 to 48 hours of ECMO trigger of acute inflammation reaction to capillary leak and intravascular volume depletion. As a result, oliguria and acute tubular necrosis follow.

Diuretic phase: After 48 hours diuretic phase begins that is the earliest sign of recovery. Diuretics are required if oliguria persists for more than48 to 72 hours.

If renal failure does not improve, continuous renal replacement therapy can be added.

Central nervous system management: regular neurological examination, preventing paralysis, and using a sedation vacation are encouraged.

Infection control: strict monitoring for infection or sepsis development is advised.

Maintain the hemoglobin >8g/dL is recommended in patients with ECMO.

Platelet transfusion is encouraged to maintain a platelet count above 100,000/mcL.

Activated clotting time should be maintained between 180-240 seconds to avoid bleeding complications.

Total parenteral nutrition can be given (fluids, electrolytes, vitamins, minerals, glucose, and proteins).

Monitor the fluid and electrolytes (potassium, magnesium, phosphorus and ionized calcium)

Discard the waste as per JMMCRI policy.

Document all relevant information in the medical record.

NM2406 – ASSISTING & CARE OF PATIENT IN IABP

Assisting & Care in IABP

DEFINITION

The intra-aortic balloon pump counter pulsation is a mode of therapy that provides temporary circulatory support to the left ventricle through controlled mechanical displacement of blood volume in the aorta

INDICATION

Left ventricular failure after cardiac surgery

Severe unstable angina refractory to pharmacologic therapy

Cardiogenic shock after MI

Post infarction ventricular septal defects or mitral insufficiency.

Emergency support following PTCA or cardiac catheterization

Hemodynamic deterioration in patients awaiting heart transplant.

PURPOSE

Decrease myocardial oxygen demand

Improve cardiac output/ejection fraction

Increase coronary artery perfusion

Decrease myocardial work load by reducing after load

Increase blood pressure

Decrease pulmonary artery pressure

EQUIPMENT

IABP insertion kit, intra-aortic balloon and console.

ECG/pressure cable from the external source into the IABP console.

Pressure monitoring set up (transducer, pressure cable, heparin saline, and saline and pressure bag).

Minor set (toothed forceps, Artery Curved forceps, straight Artery forceps, mosquito forceps, drape, sponge holder forceps, needle holder forceps, dry gauze, kidney tray, straight scissors, and bowl small)

Towel pack

Gloves, mask, cap, gown and goggle (PPE)

Arterial extension

Sutures

Antiseptic solution

Syringes 10ml, 50ml

Needle

Xylocaine 2%

Sterile blade No.11

Two large transparent occlusive dressing

PROCEDURE

Check the physician order

Identify the patient by hospital number

Explain the procedure to the patient and family

Signed consent prior to procedure

Wear PPE

Check the Coagulation results of patient before insertion.

Patient should be connected to cardiac monitor.

Patient should have patent IV access for administration of sedative and emergency drugs.

Pressure monitoring system should be connected to central lumen. Anticoagulant therapy to be continued as per doctor's order.

Insertion of IABP and preparation of IABP console

· Plug in console power card and turn power on.

· Open the helium tank and verify adequate helium supply.

· Place the ECG electrodes and connect to IABP ECG source.

· Connect the arterial line transducer to the console level and zero the transducer.

Set initial timing for inflation and deflation

· Trigger is the way the IABP identifies the beginning of the cardiac cycle (ECG trigger uses “R” wave to initiate the pumping, the pressure trigger uses arterial waveform to pump).

· For the IABP to pump effectively; the ECG signal is used to trigger the balloon and pressure signal to time counter pulsation.

· Initial IABP frequently is 1:1 and then subsequent frequency changes will be ordered by physician.

Care During insertion of IABP catheter

· Record date, time, and the patient’s tolerance to procedure.

· Record hourly IABP ratio and level of augmentation.

· Sedation may be required.

· Ensure patient is quiet and relaxed with minimal movement around bed.

· Patient with IABP catheter inserted in the femoral artery need bedrest with as minimal as possible movement of the lower extremity to avoid displacement of the intra-aortic balloon from its recommended position.

· Make sure that patient is not bending his/her legs .if the balloon pump migrate proximally can lead to vascular compromise including compromise of blood supply to the left upper extremity and stroke. If it migrate distally it can cause renal injury. If needed apply a knee brace.

· Label the IABP tubing at the insertion site as a reference point for catheter migration.

· Log roll the patient from side to side.

· Maintain infection control practices as these patients are very prone to develop bacteremia and sepsis.

· Monitor the hemoglobin/hematocrit frequently to assess thrombosis. Also monitor serum creatinine and platelet count. Watch for pyrexia.

· Obtain the chest X-ray daily to confirm the position of IABP catheter tip.

· Frequently monitor for the signs and symptoms of stroke.

· Helium gas leaks secondary to balloon rupture may lead to acute embolic stroke.in case of a suspicion of gas leak from the balloon, the patient should be placed in a Trendelenburg position, and IABP should be switched off with termination of gas supply.

· Monitor calf muscle softness and circumference to check for internal bleeding.

· Color of extremities should be monitored for cyanosis.

· Peripheral pulse should be monitored hourly to ensure the blood flow to the leg.

· Heparinized saline must be continuous.

POST PROCEDURE CARE

· Offer patient reassurance and comfort measures (patient is mildly sedated).

· Ensure strict aseptic environment during insertion.

· Establish ECG monitoring, choosing the lead with largest R wave and without artifact.

· Start IABP counter pulsation immediately after insertion.

· Adjust the duration of balloon inflation and deflation by arterial waveform.

· Compare the patient’s arterial pressure waveform with and without balloon augment to evaluate effectiveness of therapy.

· Note the difference in patient’s end-diastolic pressure and balloon associated end diastolic pressure.

· Monitor vital signs every 15 to 30 minutes for 4 to 9 hours then hourly, if stable.

· Monitor neurological status at least every two hours to evaluate for cerebral emboli.

· Monitor urine output from indwelling catheter every hour (note decrease in urine output after initiation of therapy.

· Maintain accurate intake and output.

· Report chest pain immediately.

· Treat dysrhythmia as directed.

· Check for blood oozing around IABP catheter every hours for 8 hours, then every 4 hours (anticoagulation therapy is used to prevent thrombus formation); apply direct pressure and report bleeding.

· Mark peripheral pulses in the inserted extremity to facilitate checks. (Use Doppler device for pulses difficult to palpate).

· Note complaints of pain, sensation, pressure and numbness of affected extremity.

· Observe skin temperature, color, sensation and movement of affected extremity.

· Auscultate bowel sound to detect the evidence of ischemia.

· Keep head of bed elevated 15 to 30 degrees, if tolerated.

· Assess skin frequently for signs of redness or breakdown. Pad bony prominence. Turn patient from side to side second hourly.

· Implement passive ROM exercises with exception of extremity with IABP catheter.

· Patient should be log rolled or lifted, the foot end of the bed should be elevated to 30⁰ to prevent catheter migration.

· Assess the insertions site for redness and oozing, hematoma or compartment syndrome of the limb.

· Tape the tubing to prevent dislodgement of balloon catheter.

· Obtain chest X-ray to ensure proper placement in aorta.

Weaning

Counter pulsation may be reduced from 1:1 to 1:2 and finally 1:4 depending on patient’s tolerance to weaning are

Urine output 30ml/hour, with small dose of diuretics.

Minimal need for inotropic agents to maintain cardiac output.

Stable vital signs (HR,CVP, ABP, MAP)

Removal of IABP

Article

Suture set

Dry gauze

Syringe (50cc)

Adhesive dressing

Surgical blade

Mackintosh

Antiseptic lotion

PPEs

Procedure

· Identify the patient.

· Arrange the article at the bedside.

· Ensure that the heparin infusion has been stopped before removal as per the physician’s order.

· Position the patient (supine or fowlers’ position-30⁰)

· Clean the site with antiseptic lotion

· Assist the physician to remove the suture.

· Assist the surgeon to remove IABP. Make sure not to apply pressure immediately after removal. Wait for 2-3 seconds to avoid hematoma.

· Apply pressure above the puncture site over 20 minutes (to prevent hematoma).Switch the personnel after 10 minutes.

· Apply pressure bandage after 20 minutes.

· Keep the sand bag over the pressure bandage for 6 hours.

· Monitor the vital signs (pulse) as per the protocol.

· Watch for sign of hematoma.

· Discard the waste as per JMMCRI policy.

· Perform hand hygiene.

· Document all relevant information in the medical record.

· Ambulate the patient after 24 hours.

NM2407 - THROMBOLYSIS

THROMBOLYSIS

Thrombolytic or fibrinolytic are a group of medications used to manage or treat dissolving intravascular clots. They are in the plasminogen activator class of drugs.

Thrombosis is a significant physiological response that limits haemorrhage caused by large or tiny vascular injury.

INDICATION

Acute myocardial infarction

Deep vein thrombosis

Pulmonary embolism

Acute ischemic stroke

Acute peripheral arterial occlusion

Occlusion of indwelling catheter

Stuck valve

MECHANISM OF ACTION

During thrombosis, activated platelets convert circulating prothrombin to its active form of thrombin. Active thrombin converts the fibrinogen into fibrin, eventually forming a fibrin matrix. This process is counterbalanced by plasmin derived from plasminogen, which gathers in the fibrin matrix. Tissue plasminogen activator (tPA) is a natural fibrinolytic found in the endothelial cell. Thrombolysis therapy is to convert plasminogen into plasmin which is accomplished at the location of the thrombus and on the surface of fibrin by the binding of tPA to plasminogen. This binding helps the conversion.

Fibrin-specific agents:

These agents mostly need the presence of fibrin for the conversion but, on a minimal scale (eg. Tenecteplase)

Tenecteplase

Tenecteplase has higher fibrin specificity and a longer plasma half-life with final clearance primarily through hepatic metabolism.it has a lower risk of non-cerebral bleeding. It lacks the antigenicity and is more comfortable to administer.

Non-fibrin-specific agents

These do not need fibrin presence for conversion, which is why they can do this systemically. E.g. streptokinase

Streptokinase

After binding with free circulating plasminogen, it forms a complex that converts additional plasminogen to active plasmin.

ROUTE OF ADMINISTRATION OF MEDCIATION

Systemic circulation through peripheral intravenous route

Ultrasound –facilitated catheter –directed thrombolysis (USCDT)

Thrombolytic or fibrinolytic agents are often referred to as plasminogen activator. Streptokinase and tenecteplase are currently available drugs.

PREPARATION AND ADMINISTRATION OF Inj.TENECTEPLASE (elaxim) (ACUTE MI)

Pre-medication as per protocol.

Select the dosage as per the weight of the patient.

Dilute the medicine in the sterile water (10mL) administer bolus in five seconds.

Continuous monitoring for hypotension, bleeding, anaphylactic reaction, altered sensorium, head ache and vomiting.

Patient weight	Mg	Volume in mL
<60	30	6
>60	40	6
≥80 or≤90	45	9
≥90	50	10

PREPARATION AND ADMINISTRATION OF Inj.TENECTEPLASE (20mg) (Tenectase) (ISCHEMIC STROKE)

Withdraw 10mL of sterile water for injections using the 10mL syringe.

Inject the entire contents into the vial.

Gently swirl the vial to dissolve the contents completely. Do not remove the needle and the syringe while dissolution. Do not shake the vial. Solution should colourless to pale yellow and transparent.

Withdraw the required reconstituted contents in the syringe as per body weight.

Discard the remaining solution.

Administer as an IV bolus over 5-10 seconds.

Close monitoring of the patient for blood pressure and administer antihypertensive drugs when needed.

Dosage

Patient body weight	TNK-tPA (Tenectase) dose (mg)	Volume to be administered at a dilution of 2mg/mL
60	12	6
65	13	6.5
70	14	7
75	15	7.5
80	16	8
85	17	8.5
90	18	9
95	19	9.5
≥100	20	10

PREPARATION AND ADMINISTRATION OF STREPTOKINASE (ACUTE MI)

Dosage: 15 lakh

Premedication: Phenarmine (inj. Avil), Hydrocortisone (inj. Hydrocortisone), Ondansetron (inj. emeset), Proton pump inhibitor (inj. Pantoprazole)

For bridging therapy enoxaparin sodium (inj. clexane 60mg (0.3mL IV or 0.3mL SC)

Dilute the medicine in 5mL sterile water. The diluted medicine is divided into 2 parts (2.5mL/7.5 lakh recombinant streptokinase), each dilute again in 50 mL normal saline.

Medicine is administered intravenously via syringe pump. The medicine should be administered within 60 minutes.

Anticoagulant or platelet aggregation inhibitors can be instituted as a prevention of re-thrombosis.

PREPARATION AND ADMINISTRATION OF STREPTOKINASE (PULOMONARY EMBOLISM/ STRUCK VALVE

The loading dose of Streptokinase 1-2.5 lakh according to the body weight bolus followed by 1 lakh/hr infusion. Dosage may varying according to the patient.

The maintenance dose administered for up to 3 days.

Dilute the medicine in 5mL sterile water and add to the 50 mL normal saline. Medicine is administered via syringe pump.

MONITROING

Constant neurologic and cardiovascular evaluation with blood pressure monitoring every 15 minutes during and after tPAinfusion for at least 2 hours, then half hourly for 6 hours for the next 16 hours after injection.

If there is any sign of complication, immediately stop the medicine and patient should receive an emergency computed tomography (CT).

Supportive measures such as volume correction and blood factor transfusion must be arranged in a view of bleeding.

If the patient is on concomitant heparin, protamine sulphate can be kept ready.

Fresh frozen plasma and platelet transfusion can be kept ready.

NM2408a - ASSIST IN PERICARDIOCENTESIS

DEFINITION

Pericardiocentesis is a therapeutic and diagnostic procedure in which fluid is removed from the pericardium.

INDICATION

Therapeutic

Cardiac tamponade

Diagnostic

Purulent pericarditis

A high suspicion of Neoplasm

Idiopathic pericarditis

To obtain fluid for diagnosis

To instill certain therapeutic drug.

PROCEDURE

NURSING ACTION	RATIONALE
Assess the general condition of the client.	It helps to detect the immediate management to the patient.
Send blood sample for significant investigation (PT, APTT, TC, HIV, HBsAg, and INR) and collect report.	It requires in elective pericardiocentesis.INR can be done in patients who is on warfarin.
Discontinue anticoagulants prior to procedure.
Perform investigations like Echocardiography, ECG, Chest X-ray, and collect report.	To identify the present condition.
Obtain informed consent.
Monitor and record vital signs.
Administer pre-medication if prescribed.
Identify patient and check doctor orders.
Explain procedure to the patient and relatives.
Assemble articles and labelled specimen.	Convenience for the procedure.
Provide privacy to the patient.
Position the patient (supine position with 30⁰ -40⁰ head and elevation) and connect to cardiac monitor.	This places the heart in proximity of chest wall for easier insertion of the needle into the pericardial sac.
Provide well lighted area and put off fans.
Wash hands with soap solution.
Clean the site with antiseptic solution and drape the patient appropriately.
Assist the doctor during procedure.
Communicate with the patient during the procedure.
Assist in applying a dressing over the puncture site after the procedure.
Make the client comfortable.
Monitor vital signs.
Observe the puncture site for any leakage.
Send the specimen to the labs with appropriate patient identification. Use the last withdrawn specimen for culture and cytology examination.	Last sample will be the most sterile one.
Clean dry and replace the equipment in its proper place. Discard waste as per JMMCRI policy.
Perform hand hygiene.
Document all relevant information in the medical record.

NM2409 – CARE OF PIG TAIL

ASSISTING IN INSERTION, CARE & REMOVAL OF PIG TAIL DRAIN

Pig tail is a sterile, thin long, universal catheter with a locking tip that forms a pigtail shape. The drain is used to remove the unwanted body fluids from an organ, duct or abscess and is inserted under strict radiological guidance to ensure correct positioning.

HOW LONG A PIG TAIL DRAIN CAN BE USED

A pig tail drain can be used for at least 6 weeks.

INDICATION

To remove fluid from a body cavity

To drain an abscess

To instill medication

COMPONENTS

Radiopaque polyurethane catheter

Stainless less steel trocar needle

Introducer

PRELIMINARY ASSESSMENT IN RELATION TO:

A. Patient

o Identify the patient and doctors’ orders.

o Assess the general condition of the patient.

o Collect and send the patient’s blood for BT, CT& PT and ascertain in the results are within normal limits.

o Ascertain that the site is marked (through ultrasound).

B. Equipment

o Patient’s chart & X-rays

o Cheatle forceps

o Inj. Xylocaine 2%

o J point design needle and guidewire

o Disposable syringes and needle

o Dilator with Sheath 5 or 6F

o Suture set

o Dressing tray

o Antiseptic solution

o Surgical blade

o Pigtail catheter No.5/6F

o IV fluid

o 3 way

o Personal protective equipment

o Mackintosh & draw sheet

o Echocardiogram

o Sterile specimen containers

o Kidney tray

C. Environment

o Provide privacy

o Provide a well-lighted area

o Put the fan off

PROCEDURE
NURSING ACTION	RATIONALE
Identify the patient by hospital number.
Explain the procedure to the patient and clarify the doubt.
Obtain the informed consent.
Place the patient either in supine with the head of the bed up to 40-45 degrees or in a sitting position for posterior access to effusions posterior.
Determine the best place by insertion. Optimal placement is in the safety triangle, bordered by the lateral edge of the pectoral muscle, the lateral edge of the latismus dorsi and a line along the fifth intercostal space at the level of the nipple.	Insertion here minimizes the risk of damage to the nerves, vessels and organs.
Sterilize and drape.
Measure the small bore catheter against the chest to determine how far in it should be inserted for placement into the superior aspect of the chest with all side holes within the side holes.	Pigtail can easily be drawn back but cannot be inserted further in after the procedure is completed.
Assist the anesthetist to anaesthetize the skin and deeper tissue with increasing larger needles inserted over the superior aspect of the rib and parietal pleura.
Load the finder needle with heparinized saline (0.5ml of 25,000IU in 500 ml) and assist to insert the finder needle.	It helps to visualize the aspiration of air during insertion.
Assist in introducing the puncture needle and pigtail catheter.
Connect the 3 way to the pigtail and pull back the needle sheath.
Assist in suturing the pigtail catheter.
Secure with sterile dressing.
Attach the catheter to a standard drainage system.
Monitor the patient condition throughout the procedure.
Ensure the patency of the catheter.
Make the patient comfortable.
Assess the response of the procedure.
Monitor vital signs.
Initiate IV fluid after aspiration.
Send the specimen to the lab with appropriate patient identification.
Arrange the temporary pacemaker if necessary.
Discard the waste as per JMMCRI policy.
Perform hand hygiene.
Document all relevant information in the medical record.

Removal of pig tail drain

Equipment

Dressing pack

Dry gauze

0.9% saline

Skin closure strips

Straight scissors

Suture cutter

Occlusive dressing

Plastic baked protective sheet/ mackintosh

Personal protective equipment

PROCEDURE
NURSING ACTION	RATIONALE
Identify the patient by hospital number.
Explain the procedure to the patient and clarify the doubts.
Place the patient either in lateral recumbent position or supine with the head of the bed up to 40-45 degrees or in a sitting position for posterior access to effusions posterior.
Drape the patient.
Encourage the patient to take deep breaths and release muscle tension during exhalation. Throughout the procedure.
Remove the dressing and ancho tape using clinically clean gloves.
Thoroughly cleanse the drain insertion site and the first 10cm of the drain with skin cleansing solution2% chlorhexidine and 70% of alcohol or equivalent.
Dry the area with gauze.	To ensure occlusive dressing adhere to the skin.
Straighten the curled drain tip (internal end).	This can be achieved either by cutting off the external part of the drain (thereby cutting the tensioning string inside) or preferably by turning the lock (which, in the 'close' position, puts tension on this string) at the external end of the drain to 'open'.
Identify anchor suture, cut and remove the suture whilst supporting the drain.	To prevent tension on the insertion site.
Hold the drain in dominant hand whilst gently pinching the skin at the insertion site with non-dominant hand.
Remove the drain swiftly but gently while simultaneously pinching the skin with non-dominant hand.
Check the tip of the drain is intact.
Cut excessive suture material, dry the skin and apply occlusive dressing.
Perform hand hygiene.
Assist the patient in comfortable position and assess patient condition. Chest auscultation or chest X-ray can be done.
Advice the patient to rest for one hour or until reviewed.
Discard the waste as per JMMCRI policy and perform hand hygiene.
Document all relevant information in the medical record.

NOTES

There should be no excessive force required to remove drain. If any resistance is met, STOP the procedure and review the device / procedure for additional sutures or locking device. If resistance continues STOP the procedure and call for medical assistance.

Review the dressing for signs of air or fluid leakage daily.

Inspect the insertion site for signs of local cutaneous sepsis or continued drainage once per shift.

Take down the occlusive dressing after 48 hours to inspect the site.

NM2501a - MANAGING OR HANDLING OF CHEMOTHERAPEUTIC DRUG

DEFINITION

Chemotherapy is a systemic treatment with antineoplastic agents (cytotoxic drugs) in an attempt to kill cancer cells by interfering with cell division and cellular dysfunction.

PURPOSE

Treat the disease

Control the tumor growth

Improve the quality of life for patients with uncontrolled disease

PROCEDURE PRE PREPERATION

NURSING ACTION	RATIONALE
Obtain informed consent regarding treatment with chemotherapeutic agents.	Any form of treatment and knowledge related to it, is the fundamental right of the patient.
Record the patient’s current height and weight on medical record.	Necessary for calculating the right dosage of the drug.
Calculate the body surface area	BSA is essential for calculating the exact dosage of the drug.
Verify and document Absolute neutrophil count (ANC).	Administration of the drug is to be avoided during the neutropenic phase; which could be fatal
Verify with the physician if the values are reviewed and is within normal limits and documented.	Ensures the prevention of adverse toxic effects.
Verify the duration between each cycle and levels.	Adhering to protocol avoids overdose which in turn prevents lethal effects.
Ensure that that the chemotherapy orders are written clearly (name of the drug, dosage, diluents, route, duration of administration and pre- premedication) with the date and signature of the physician with counter sign of the consultant.	Ensures safe administration of drugs.
Do not carry out verbal or unclear orders.	Drug errors are lethal.
Put on the ultraviolet light of the laminar hood of the biosafety cabinet 20-30 minutes prior to the preparation of the drugs.	The inner surface of the laminar hood when sterile assures asepsis.
Clean the work area with spirit thoroughly.	Prevents infection in neutropenic patients is an absolute necessity.
Switch on the air flow	Create negative pressures inside the laminar hood.

EQUIPMENT

· Injection trolley with spirit, cotton ball, sharps container, hand rub, adhesive tape and straight scissors.

· Disposable syringes

· Vertical laminar air flow/ biological safety cabinet

· Personal protective equipment (nitrile gloves-2, mask, apron, goggles)

· Premedication

· Normal saline

· IV fluid with twin cap port system

· Chemotherapy drugs and IV fluids

· Drug label

· IV flow regulator/ Infusion/syringe pump

· IV stand

· Kidney tray

PREPRATION OF LAMINAR HOOD

Preparation of laminar hood

The staff assigned for the patient should be present throughout the preparation of the drugs along with the trained personnel (doctor/ nurse/ pharmacist) who will reconstitute the drugs, to counter check the drug, dosage, route and dilution. Assemble the needed equipment in the cytotoxic drug preparation area.

Reconstitution of chemotherapy drugs

NURSING ACTION	RATIONALE
Prepare the labels and keep it beside the IV bottles /pouches along with the specific chemotherapy drug (When more than one drug has to be to prevent lethal complications mixed at the same time.)	Preventing error during preparation is important
Wash hands /wear personal protective equipment	Avoids the exposure to the cytotoxic drugs and protects the health personnel from lethal effects.
Spread a sterile disposable paper inside the laminar hood and place the spirit swabs, syringes as required.
Check the IV fluids for expiry, of color and precipitation. Open the IV fluid, wipe it spirit swab.	Bacterial contamination can be detrimental to patient.
Open the drugs (vials/ampoules) away from the body. Wipe the top of the vial with spirit swab in circular motion and keep the cotton aside.
Rub hands with hand rub and wear the gloves.	As a measure of preventing the spread of health care associated- infections.
Disinfect the rubber of medicine vial.
Remove aluminum foil of IV fluid.
Spike vertically transfer cap on the IV fluid.
Spike the vial onto the transfer cap.	Prevents high pressure being generated inside the sealed vials.
Reconstitute by applying pressure with two hands.	Prevention of cytotoxic splash/ spillage is an important responsibility of the loading nurse
Transfer reconstituted drug back to the bottle and mix with the IV fluid.
Label the drugs correctly and get it signed by the assigned staff (chemo checklist as well as the label.)	Counter verification ensures patient safety.

ADMINISTRATION OF CHEMOTHERAPY

NURSING ACTION	RATIONALE
Wear personal protective equipment ( apron, mask and goggle)
Pre-medicate the patient as per the physician’s order.
Transport the reconstituted drugs to the patient’s bedside
Counter check with the second nurse for the rights of drug administration.	Prevents errors of the drug.
Wash hands/use hand rubs and wear the nitrile gloves.
Administer the drug in a sterile manner	Prevents contamination of the drug.
Set the rate of infusion (drops or ml) using IV flow regulator/ syringe pump or infusion pump.	Delivers the drug accurately.
Monitor vital signs as per the checklist and observe for any adverse reactions. E.g. tachycardia, dyspnea or allergic reactions.
Monitor the rate of infusion as per the plan. Check the backflow to in-between the administration of medicine.
Document the drug in the chemotherapy drug administration record and obtain counter signature from the second nurse.
Discard all the material which have been used for cytotoxic drug preparation (syringes, cotton, mask, apron, gloves, ampoules and vials) in a waste liner with cytotoxic symbol and seal it with adhesive.
Discard the needles in the sharps container and wash hands.

MANAGEMENT OF EXTRAVASATION

Extravasations is the leakage of chemotherapeutic agent from the vein into the subcutaneous tissues. Substances that can cause tissue necrosis and damage, particularly when extravasated.

PROCEDURE

NURSING ACTION	RATIONALE
Stop the chemotherapeutic drug infusion immediately.	Prevents further damage to the tissues.
Aspirate any residual drug from the cannula and suspected infiltration rate.	Prevents further damage.
Leave the IV cannula in place	Essential for aspiration of the residual drug and to administer antidote.
Inform the physician as soon as possible.
Apply cold / hot applications. Cold application (ice pack) for Daunorubicin, Doxorubicin, Mitoxantrone. Hot application (hot water bag) for Vincristine, Vinblastine.	Neutralize the drug effect. Topical cooling diminishes pain and discomfort by causing vasoconstriction, and localizing extravasated vesicant. Heat causes vasodilation, increases drug distribution and absorption and decreases local drug concentrations.
Cover with sterile dressing and elevate the extremity.	Prevents infection reduces edema.
Check the site frequently for erythema, pain, blisters and necrosis.	Monitors tissue damage.

Documentation of extravasations

Date and time

Catheter size and type

Insertion type

Drug used

Approximate amount of drug extravasated

Nursing measures

Patient’s complaints

Appearance of the site

Notification to the physician

Follow up measures

Signature

SPILLAGE MANAGEMENT (CYTOTOXIC DRUGS)

Must be performed by a staff nurse

Equipment

Spill kit with two pairs of heavy duty latex gloves, gown, goggles, mask, cap, shoe cover, tissue paper.

Caution board that alert other personnel and limit access to the area of spill.

Concentrated alkaline detergent solution.

Bottled water (for dilution of the detergent).

Cytotoxic waste disposable container/bag.

NURSING ACTION	RATIONALE
Place caution board	Alerts others with regard to potential hazard and limit access to the area of spillage
Wear personal protective equipment as needed.	Protects the health personnel.
Spread the tissue paper over the spill.
Pour the diluted alkaline detergent solution over the tissue paper.
Wipe of the tissue paper and dispose in a yellow liner with cytotoxic symbol.	For safe disposal.
Clean any cytotoxic spill from the outside of the spill area and gradually work towards the center.	This limits the spread of drug.
Clean the contaminated surfaces thoroughly with soap and water
Perform hand hygiene.
Remove soiled contaminated linen from patient’s bedside.
Place the linen in yellow liner with cytotoxic symbol.
Send contaminated linen to the laundry separately with instructions to wash these linen using personal protective equipment.
Clean the contaminated area with absorbent pads and detergent solution.
Perform hand hygiene.
Document all information in the medical record.

NM2502a - BIOSAFETY CABINET (BSC)

A bio-safety cabinet conduct all procedures involving the manipulation of potentially infectious materials, including aerosol producing activities, when using aerosol-producing equipment, or when using high concentrations/ large volumes of organisms, inside a bio-safety cabinet.

Class II category biosafety cabinets are used in hospital for personal, environmental and product protection.

USE A BIO-SAFETY CABINET (BSC)

· Conduct all procedures involving the manipulation of potentially infectious material, including aerosol-producing activities, when using aerosol-producing equipment, or when using high concentrations/ large volumes of organisms, inside a bio-safety cabinet.

· Storage of excessive materials or equipment inside a BSC can disrupt airflow, resulting in turbulence, cross-contamination, or breach of containment. Therefore, only materials and equipment necessary for immediate work will be placed in BSC. Additionally, storing items on top of the BSC can interrupt exhaust airflow and can result in damage to the BSC. Place large items close to the side walls, rather than at the back of cabinet will interfere with proper functioning of the cabinet, which can cause a loss of containment of infectious organisms.

· Prior to each use examine the cabinet to ensure it is clean and in good repair. Verify that the cabinet blower is on and functioning properly based upon observance of Magnehelic gauge and /or digital readouts. Ensure that UV lights are disengaged prior to commencing work In the BSC.

· Wipe interior of BSC (work surface, walls & interior surface of window) and items placed in the cabinet with an efficacious and approved disinfectant.

· Ensure the cabinet drain valve is closed prior to starting work, to contain spills.

POINTS TO BE NOTED

· Place items necessary for the procedure (including a receptacle for waste) in BSC prior to initiating work. This will minimize the number the number of arm-movement disruptions to the air barrier, which can compromise the containment of the BSC.

· Arrange the materials within the cabinet in a manner to ensure good aseptic technique, e.g., all workflows from one side of the cabinet (clean) to the other side (dirty). Contaminated items never cross over uncontaminated/ clean supplies.

· Verify that the sash is set at the appropriate height.

· Cabinets are designed for a single operator. More than one person working in the BSC at one time (even in a six-foot BSC) produces enough disturbances in the airflow to breach the containment of the BSC. Never lean into a BSC or place head into a BSC.

· The BSC must be emptied and decontaminated at the end of procedure and/or workday. Every individual is responsible for cleaning the BSCs when they have finished working. This cleaning involves following steps:

· Remove all items from the bio-safety cabinet. Surface decontaminated material prior to removing from cabinet.

· Place all waste in an autoclaving bag in the bio-safety cabinet and seal prior to removing.

· Wipe the interior surface of the cabinet with an approved disinfectant after all items have been removed from the cabinet.

· Air currents and drafts can disrupt BSC airflows. Locate BSCs away from doors, vents/ diffusers and traffic paths.

· Do not store equipment or supplies inside the cabinet.

· Make sure that items necessary for procedures are inside the BSC prior to starting work in the BSC.

· To prevent disruption of airflow and damage to the HEPA filter, do not store items on the top of the cabinet.

· Prevent damage to cabinet by keeping all objects (i.e. paper towels, wipes) from being pulled into the back, front, and side grills or slots.

· Never disengage the alarm. The alarm indicates when the cabinet has improper airflow or reduced performance, which may endanger the researcher and/or the experiment.

· Avoid rapid motions at the front of the unit and minimize movement of arms in and out of cabinet the air curtain.

· Protect vacuum lines by using an appropriate trap system with primary and overflow flasks containing an approved disinfectant and a hydrophobic HEPA filter between the trap system and the vacuum pump or house vacuum system.

NM2503 – INSERTION, CARE & REMOVAL OF CHEMOPORT NEEDLE

CHEMOPORT

Chemo port is an implantable subcutaneous venous access port. The most common insertion site is right internal jugular vein.

Benefits

The port can be used for fluid and blood transfusion.

The port simplifies the process of blood draws for lab testing

The port can be used to inject dye for PET and CT scans.

The port can be used for long term.

PROCEDURE

NURSING ACTION

Identify the patient by hospital number-

Check for physician order regarding the site of chemo port insertion.-

Monitor for vital signs (blood pressure, pulse).-

Prepare the area of insertion.-

Assist anesthetize the insertion site.-

Assist the physician to make incision site below the collarbone.-

Assist the physician to insert the catheter.-

The physician then connects the catheter to the port. The port is placed in a small pocket created under the skin in the chest area -

Confirm the port by injecting the fluid -

Assist in suturing the site-

Apply sterile dressing.-

Confirmatory procedure like X-ray can be arranged.

CARE OF CHEMOPORT and MEDICINE ADMINISTRATION

The chemo port can be used for administration of fluid or medicine one day after the insertion or as per physician’s order.

EQUIPMENT

· Huber needle/ Chemo port needle

· Normal saline /Heparinized Saline

· Syringe 10mL

· Hole Towel

· Transparent Adhesive Tape

· Antiseptic Solution (Spirit, Betadine)

· Dry Gauze

· Small Bowl small -2

· Artery curved Forceps

· Kidney tray

· Personal protective equipment

PROCEDURE
NURSING ACTION	RATIONALE
Identify the patient by hospital number.
Prepare the necessary article at the bedside. Two staff nurse are required for care of Chemo port needle
Flush the Huber needle with heparinized saline before accessing the venous device.
Cleanse the area with antiseptic solution (spirit-betadine-spirit) in a circular motion and wait for dry.
Place the hole towel over the cleaned site.
Use the non-dominant hand to stabilize the port.
Insert the needle into the port at a perpendicular direction.
Check the patency of the line.
Flush the line with 10ml heparinized saline before administering medicine.
Fix the Huber needle with transparent adhesive tape.
Infuse the normal saline infusion (100ml) before administering diluted chemotherapeutic drug and monitor throughout the procedure for any complication like infection and thrombosis.
Flush the line with 10 mL heparinized saline
Remove the Huber needle by applying counter pressure on the chemo port by non-dominant hand.
Monitor the patient for any complication.
Discard the waste as per JMMCRI policy.
Document all relevant information in the medical record.

Note

Once the chemotherapy stops, flush the line with heparinized saline and followed by normal saline infusion (100ml) every month for the maintenance of chemo port needle.

REMOVAL OF CHEMOPORT

Chemo port is removed when it is infected or when no longer it is needed.

NM2601 – CARE OF PATIENT WITH BURNS

Burn patient management focuses on immediate first aid, wound care, pain management, and preventing complications like infection and shock.

PURPOSE

· To correct fluid and electrolyte imbalances

· To initiate life saving measures without delay

· To prevent infection

· To manage pain

· To restore function

ARTICLES for

§ Starting intravenous infusion

§ Maintaining aseptic precautions and isolation technique

§ Urinary catheterization

§ Monitoring vital signs

§ Monitoring ECG

§ Nasogastric insertion

§ Intubation

§ Obtaining blood for initial investigations

§ Emergency trolley (adult, pediatric)

§ Dressing material

CONTINUOUS MONITORING REQUIRED ON

· Airway

· Gas exchange

· Fluid volume

· Tissue perfusion

· Risk for infection

· Hypothermia

· Pain

· Nutrition

· Skin integrity

Airway

Airway may be compromised due to tracheal edema or interstitial edema in inhalation injury or circumferential torso burns

· Monitor for oxygen saturation.

· Check for ABG and chest x-ray

· Check for respiratory rate, character and level of consciousness.

· Monitor breath sounds for every 4 hours.

· If not intubated assess for stridor, hoarseness and wheezing hourly.

· Administer humidified oxygen to maintain 95% saturation.

· Assist in coughing and deep breathing exercise and do suction every 1-2 hour, if needed.

· Mobilize every two hours and monitor for sputum characteristics.

· Raise the head of the bed to 30 degree.

Fluid volume

As the fluid shift into the interstitium and evaporation of fluid from the injured skin.

· Monitor vital signs and urine output until stable.

· Check for mental status (GCS) every one hour.

· Administer fluid requirements as per urine output and hemodynamic instability.

Tissue perfusion

Circumferential burns leads to compression and impaired vascular circulation, observed by decreased or absent peripheral pulse.

· Assess the peripheral pulse, capillary refill for 72 hours.

· Elevate the upper and lower extremities to decrease the edema formation.

· Check for ECG and cardiac enzymes in electrical burns.

Pain

Burn trauma develops pain.

· Assess the pain by Numerical rating scale (NRS).

· Monitor physiological response of pain such as blood pressure and heart rate.

· Administer prescribed analgesics or anxiolytics.

Infection

Skin loss, impaired immune response and invasive therapies

· Check for temperature, vital signs.

· Provide meticulous care.

Nutrition

Stress and wound healing increase metabolic demands

· Place nasogastric tube for gastric decompression in >20% TBSA burns.

· Assess abdominal and bowel sounds every 8 hours.

· Assess NG aspirate (color, quantity and pH )

· Administer prescribed stress ulcer prophylaxis.

· Initiate enteral feeding and provide high calorie protein.

Hypothermia

External cooling and skin loss leads to hypothermia

· Monitor for body temperature.

· Prevent evaporative and conductive losses. (Minimize skin exposure and maintain environmental temperature.

Physical immobility

Skin graft and therapeutic splinting leads to impaired physical mobility.

· Perform active and passive range of motions exercises to extremity.

· Elevate extremities.

ASSISTING WITH FLUID RESUSCITATION IN ACUTE BURNS

The ideal burn resuscitation is the one that effectively restores plasma volume, with no adverse effects. The fluid resuscitation and infusion depends on the urine output of the patient.

Suggested and followed formula is Parkland formula.

· Initial 24 hours: Ringer’s lactated solution 4ml/kg/% burn for adults and 3ml/kg/% burns for children. RL solution is added for maintenance for children:

o 4ml/kg/hr for children weighing 0-10 kg.

o 40ml/hr+ 2ml/ hr for children weighing 10-20kg.

o 60ml/hr+1ml/kg/hr for children weighing 20kg or higher.

o This formula recommends no colloid in the initial 24 hour.

· Next 24 hours: Colloid given as 20-60%of calculated plasma volume. No crystalloids. Glucose in water is added in amounts required to maintain a urinary output of 0.5-1ml/hr in adults and 1ml/hr in children.

RECOMMENDED SOLUTIONS AND PREDICTED COMPLICATIONS

IV FLUID	COMPLICATION
Normal saline	Hyperchloremic acidosis
RL	Increase neutrophil activation
Crystalloids	Coagulability
Hypertonic solution	Hypernatremia, renal failure
Colloids	Allergic reactions, coagulopathy, renal failure

NM2602 – BURNS WOUND DRESSING

BURNS WOUND DRESSING

JACKSON’S BURN WOUND MODEL

The burn is divided into 3.the inner zone of a burn is the zone of coagulation. This area is dead. The outer zone of the burn is called zone of hyperaemia. This is reactive zone of inflammation in response to the injury, which can occur with non-burn injuries such as trauma, and will return to normal within hours of the injury. The middle zone of the burn is called the zone of stasis which the target of good burns care gives chances of recover rather than deepen and become the part of zone of coagulation.

TYPES OF BURN

Superficial Epidermal Burn

(E.g. sunburn, minor scald, brief flash burn, where there is erythema of the skin but no break in the skin or blistering) does not require a dressing and application of emollient or moisturizer to cool the intact but painful skin is appropriate.

Superficial Dermal Burn

A superficial dermal burn (hot water scald, where there is skin blistering over a wet, pink and painful dermis) requires a dressing to absorb fluid, avoid maceration and seal the wound from the outside environment to reduce pain and infection.

Deep Dermal or Full Thickness Burn

A deep dermal or full-thickness burn (e.g. prolonged flame, contact burn, where skin under the broken or destroyed blister is less painful and a fixed red or pale white color due to damaged blood vessels, proteins and nerve endings ) will require a dressing to debride and lift the dead skin if it is a small area or to temporize for surgery if it is larger area.

ASSESSMENT OF BURNS

Type	Appearance	Capillary Refill	Sensation	Healing Time	Scarring
Superficial Epidermal Burn	Dry And Red, No Blisters	Blanches	Yes	Within 7 Days	No
Superficial Dermal Burn	Pale Pink, Blisters	Blanches	Very Painful	Within 14 Days	Pigmentation Change, Low Risk Of Scar
Deep Dermal Or Full –Thickness Burns	Res And Fixed Stained, White Or Black, Leathery	No	No Or Reduced	>21days	High Chance Of Hypertrophic Scar

PURPOSE

· To protect the wound from contamination of microorganisms

· To aid homeostasis

· To support /splint the wound site

· To protect the client from seeing the wound surface

· To promote thermal insulation of the wound surface

· To provide maintenance of high humidity between the wound and dressing

· To provide comfort

TYPE OF DRESSING

Nano crystalline silver dressing (Acticoat)

Ø Slow release of silver which is toxic to micro-organisms.

Ø Moisten silver dressing with sterile water, (the chloride ion in the saline could bind to the silver ion, reducing the amount of silver delivered to the wound)

Ø It is preferred to apply a second dressing, followed by wet gauze, dry gauze and a bandage or adhesive dressing.

Hydrocolloids (Duoderm, Granuflex)

Ø Cross-linked adhesive dressings of gelatin, pectin or carboxymethyl cellulose.

Ø Good for low or moderate exudating burns- contacts and holds exudate as a gel inside the dressing.

Ø Appropriate for all burn depths

Ø Water repellent and confirmable.

Foams

(Allevyn, bitatin, Mepilex)

Ø Suitable for high exudating burns. Thereby prevent hyper granulation and maceration

Ø Reduce requirement for dressing changes

Alginates

(algisite M , Kaltostat)

Ø Highly absorbent, biodegradable dressings from seaweeds and contain calcium.

Ø Use on small granulating tissue or small superficial dermal areas of burns

Ø Good for hemostasis if fragile or superficial bleeding

Ø Useful under a retention dressing.

Ø Need to soak with water or oil to remove alginates.

Hydrogel

(intrasite, hydrosorb )

Ø Hydrophilic interactive dressing with very high water content

Ø Able to donate water to the burn and rehydrate dry eschar or necrotic slough and absorb exudate also

Ø Good for mid-dermal or deeper burns

Ø No harm or granulation tissue or epithelialization

Bismuth –impregnated petroleum gauze

Ø Preferred dressing for graft donor sites, fresh graft site, superficial partial –thickness burns.

Ø Suitable for pediatric population

GENERAL INSTRUCTIONS

Ø Wound dressing depends on the characteristics and size of the wound

Ø Wound should be dressed with an appropriate dressing material

Ø Use occlusive dressing to reduce the heat lose and minimize cold stress

Ø Administrative analgesics 30 minutes prior to procedure.

Ø Dry gauze alone should be avoided as it promotes scab formation, which will generally separate spontaneously as re-epithelialization occurs.

EQUIPMENT

Ø Nonsterile gloves

Ø Cleansing solution

Ø 25 and 21 gauge needle

Ø Syringe 10mL

Ø Local injectable anesthetic

Ø Sterile straight scissors, forceps

Ø Non adherent dressing

Ø Absorptive bulk dressing

Ø Rolled gauze wrap

PROCEDURE

Initial care of Burn wound dress

Ø Identify the patient by hospital number.

Ø Diagnose and treat serious associated injuries.

Ø Remove all clothing and gross debris from wound.

Ø Remove all valuables from the patient and also any item that is distal to the burn to prevent entrapment from potential edema.

Ø For, chemical burns, irrigate with tap water for at least 20 minutes to remove any residual chemicals.

Ø For, thermal burns, irrigation will cool the injured area to prevent additional thermal damage.

Ø During first 30 minutes after injury, use room temperature (20-25⁰C) or cold tap water irrigation, immersion or compressors to limit the extent of the burn and provide significant pain relief. Do not immerse burned tissue in ice or ice water because ice immersion increases pain and burn depth and increases the risk of frostbite and if the burn surface is large, systemic hypothermia.

Ø Treat pain as soon as possible. Prescribed analgesics can be given concurrently with initiation of irrigation.

Ø Ensure that irrigation has removed all clothing and debris from the burned area.

Ø Cover the burn with moist sterile dressing soaked in room temperature water or saline. The dressing should be kept cool and moist to provide continued pain relief.

Ø Give Td/Tdap injection

Definitive burn wound care

Ø Cleanse the burned area gently with a clean cloth or gauze and soap and water or a mild antibacterial wound cleanser such as chlorhexidine.

Ø Irrigate the wound with saline water.

Ø Debride the desquamated skin and broken blisters by peeling from the wound and excising with straight scissors close to the border with viable, attached epidermis.

Ø Apply a sterile burn dressing, with or without topical antimicrobial cream /ointment.

Ø Dressing should be sterile and have an absorptive layer sufficient for the amount of exudate expected.

Ø Cover the wound surface preferably with a fine mesh gauze or commercial non-adherent gauze.

Ø Cover and pad the wound with additional layers of loose gauze fluffs with which can absorb exudate from the burn wounds more effectively than gauze pads.

Ø If fingers and toes are involved pad the web spaces and the digits individually and separate them with strips of gauze.

Ø Wrap the entire dressing with an absorbent, slightly elastic material.

After care

Ø Administer the prescribed analgesics

Ø Elevate the affected limb to prevent swelling, which may cause delayed healing or infection.

Ø For burns of the face and neck, encourage the patients to sleep with their head elevated to help minimize or decrease swelling.

Ø Discard the waste as per JMMCRI policy

Ø Perform hand hygiene.

Ø Document all relevant information in the medical record.

Dressing Changes

Ø Dressing should be checked at 24 hours.

Ø Reassess the burn wound at 48 hours and change the dressing.

Ø Subsequent dressing changes depends upon the healing progress in 3-5 days.

NM2701 – JEJUNOSTOMY FEEDING

DEFINITION

Fluid administered through jejunostomy is called jejunostomy feeding.

PURPOSE

§ To administer liquid food to maintain nutrition.

§ To prevent regurgitation/ aspiration.

INDICATION

§ Gastrointestinal resection of the esophagus, stomach, pancreas and duodenum

§ Gastroparesis

CONTRAINIDCATION

§ Abdominal wall infection at the placement site.

§ Severe ascites

§ Peritonitis

§ History of bowel necrosis

§ Severe coagulopathy

§ Hemodyanamic instability requiring the use of vasopressors

ARTICLE

§ Towel

§ Measuring cup

§ Mackintosh

§ Disposable 50cc syringe

§ Gauze piece

§ Cup/ounce glass

§ Prescribed feed

§ Gloves

§ Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Check doctor’s order
Identify the patient by hospital number.
Explain the procedure to the patient	Help to relieve anxiety and sets the stage for patient participation.
Provide privacy
Position the patient in semi fowler’s (30-45⁰)	Prevents regurgitation and aspiration.
Place mackintosh and towel.	Protects patient gown and linen.
Wash hands
Put on clean gloves.	Protects direct contact GI secretions.
Check the label of jejunostomy tube	Ensures the tubing is correct
Pinch and clamp the jejunostomy tube and remove the cork/cap	Prevents excessive air from entering patient stomach and leakage of gastric contents.
Remove plunger from syringe and attach barrel of syringe to end of tube.	Barrel receives formula for installation
Fill the syringe with the feed and release the clamp.	Allow the feed to flow
Raise the syringe not more than 15 cm (18 inches) above insertion site.
Repeat until the prescribed amount of feeds are given.	Flush feeding tube with water at the end of a feeding.
Cork/cap the end of the feeding tube.
Replace the equipment.
Remove gloves and wash hands.
Discard the waste as per JMMCRI policy
Document the relevant information in the medical record.

COMPLICATION

§ Intestinal obstruction

§ Pneumonia

§ Nausea, vomiting

§ Abdominal distension

NM2702 - PERCUTANEOUS ENDOSCOPIC GASTROSTOMY TUBE FEEDING

DEFINITION

PEG feeding is the administration of nutrition, fluids, and medications in to the stomach through a tube.

INDICATION

To provide nourishment to client who are unable to ingest food by mouth or by naso-gastric tube.

Massive head and neck injuries

Carcinoma of neck, throat and upper GI tract

Congenital anomalies

PURPOSE

To provide longtime nutritional support and medications.

EQUIPMENT

§ Feeding formula

§ 2mL catheter tip syringe.

§ Measuring glass

§ Mackintosh and towel

§ Kidney tray

§ Gloves

§ Feeding pump

§ Glass and water

General instructions

§ Perform daily skin care

§ Assess the exit sites at least once each shifts. Examine the area of erythema drainage, and other skin problems.

§ Always check tube placement before administering feeding and medication.

§ Monitor for complications, such as aspiration. Diarrhea, abdominal distension, hyperglycemia, constipation, fecal impaction.

§ Elevate the head of the bed at least 45 degrees or as recommended

§ Check for residual volume (if gastric residual volume> 250ml x2 may require gastric motility agent. If GRV>500mL hold feed and reassess residual one hour after and if residual is still more than 500mL notify the physician and flesh tube with water.

§ Gastric residual volume is the amount aspirated from the stomach following administration of enteral feed.

§ Flush the gastrotomy tube with50mL of water every 8 hours to prevent clogging.

GRAVITY FEEDING•/SYRINGE

STEPS	PROCEDURE
Identify the patient by hospital number.
Explain the procedure to the patient
Perform hand hygiene and wear PPE
Assist the patient to sit up with head elevated at least 45 degrees. Pillows may be used to support the patient
Expose the gastrostomy tube.
Aspirate stomach contents to verify the placement. If it is greater than 100mL delay the feeding for 30 minutes for one hour, and check again. Auscultate the abdomen for this present bowel sounds. Notify the physician of the high gastric residuals, absence of bowel sounds, or patient complaints of abdominal discomfort before administering the feedings.
Flush the tube with 50 mL of water
If the patient coughs or chocks, do not administer feeding and notify the physician.
Clamp gastrostomy tube.
Remove the plunger from the syringe. Attach the syringe to the gastrostomy tube
Pour the prescribed amount of feeding into the syringe, open the clamp, and allow it to empty in, adding more feeding as the syringe
Clamp the tube before it empties and remove the syringe.
Close the feeding port and clamp the tube.
Clean the peristomal area .Change the dressing as soon as it becomes moist make the patient comfortable.
Clean and replace the document.
Discard the waste as per JMMCRI policy.
Document procedure and patient toleration, condition of the gastrostomy site and potency of the tube ,amount and character of any gastric return, tube patency, gastrostomy site care and any patient / caregiver/ instruction on the patient visit report

GRAVITY FEEDING /FEEDING BAG STEPS

Hang a container of feeding solution on an IV pole about 18 inches above the patient’s shoulders
Adjust the delivery rate with flow regulator
Refill the feeding bag before container is empty for continuous infusion.
Add 50mL warm water to the bag when the last of the formula reached to the feeding tube to clear the tube.
Close the feeding port caps or clamp the feeding tube to prevent a return flow of feeding when changing the bag or when the feeding is near the completion
Clean the feeding bag with liquid soap and water. Rinse well and air dry. The feeding bag may be cleaned and reused 3 or 4 times.

FEEDING PUMP

Connect the formula feed to the feeding pump.
Turn the pump on at the prescribed flow rate, and allow the feeding bag to flow through the tubing. Turn the feeding pump off.
Connect the free end of feeding bag tubing to the gastric tube; unclamp the tube and turn on the pump.
Intermittently, observe the flow to make sure that the tubing is not blocked or kinked, in which case the pump alarm should sound.
Refill the feeding bag before container is empty.
Add 50mL of warm water to clear the tube when the last of the formula has reached the feeding tube.
Close the feeding port caps or caps or clamp the tube to prevent a return flow of formula when you are changing the bag or when the feeding is near completion.
Clean the feeding bag with liquid soap and water. Rinse well and air dry. The feeding bag may be cleaned and reused 3 or 4 times.

MEDICATION ADMINISTRATION

§ Check the placement.

§ Prepare each medication.

§ Take medication that need to be dissolve second.

§ Measure the liquid amount of liquid medication, or crush pills and dissolve powder in 15mL or as ordered.

§ Remove the plunger from the 50mL syringe. Pour 30mL of water into the syringe and flush the tube.

§ Pour medication into the syringe. Do not use the syringe plunger to push the medication into the tube. Let the medication flow in slowly via gravity.

§ Finish the tube with 30mL of water after all medications have been given.

§ Wait before restarting tube feeding.

§ Some medications don’t work when mixed with the feeding formula.

§ Keep the clamped in between feeding.

POST PROCEDURE CARE

TUBE FEEDING

§ Sit upright or at least 45 degree angle during feeding and for 1 hour following the end of feeding.

§ Flush tube with 60 cc warm water before and after each feeding to keep the inner surface of the tube clear.

§ After flushing, clamp tube closed between feeding to prevent leakage.

MEDICATION ADMINISTRATION

§ Do not mix medication with feeding formula

§ Medication should be given in liquid form if possible. If only pills are available, crush finely. Mix the powder in water until there are no clumps.

§ Give each medication separately. Flush tube with 10cc of water between medications.

§ Flush tube with 60cc warm water before giving any medications and again before tube is claimed off.

NM2801 - ASSISTING IN SUTURING

SUTURE

Surgical suture is a medical device used to hold body tissues together after an injury or surgery. The word suture derived from Latin word “SUTURA” means to sew, stitch or tack together.

PURPOSE

To hold the wound margin together to promote wound healing by first intention.

To approximate the wound margin to minimize wound contamination with food debris.

To arrest hemorrhage.

TYPES OF SUTURING

· Suture material can be classified as

• Absorbable

• Non-absorbable.

· Suture material can be classified according to the actual size

•Monovalent sutures

•Braided sutures

· Suture material can be classified according to the types of material

•Natural

•Synthetic.

TYPES OF ABSORBABLE SUTURE

Gut Natural monofilament suture is used for repairing internal soft tissue wounds or lacerations.

Polydioxanone (PDS) Synthetic monofilament suture is used to soft tissue wound repair and pediatric cardiac surgery.

Poliglecaprone (monocryl) -Synthetic monofilament suture is used in general use in soft tissue repair.

Polyglactin (vicryl) Synthetic braided suture is good for repairing hand or facial lacerations.

TYPES OFNON- ABSORBABLE SUTURE

Nylon A natural monofilament suture.

Polypropelene (prolene) A synthetic monofilament suture.

Silk A braided natural suture.

Polyester (ethibond) A braided synthetic suture.

ARTICLE

· Needle holding forceps

· Straight Forceps

· Straight scissors

· Scalpel no.11

· Needle

· Dry Gauze

· Tweezers

· PPE

· Kidney tray

· Antiseptic solution

· Antiseptic ointment

· Adhesive tape (if needed)

SUTURE TECHNIQUE

Continuous suture - This involves a series of stitches that use a single strand of suture material

Advantages

• Suture can be placed rapidly.

• Strong.

• Tension is distributed evenly throughout the strand.

Interrupted suture

This uses several strands to close the wound. After a stitch is made, the material is cut and tied off. This technique leads to a securely closed wound. If one of the stitches breaks, the remainder of the will still holds the wound together.

Advantages

· Easy to place

· High tensile strength

· Individual sutures can be removed

· Wound drainage is uninterrupted.

Deep suture

This suture placed under the layers below to the skin. They may either be continuous or interrupted.

Advantages

· Reduce tension on skin suture

· Minimize the dead space

· Improve the wound strength

Buried suture

Buried suture are used as a part of a layered closure in wounds under moderate-to-high tension.

Advantage

· Reduces tension on skin

· Improving cosmesis

· Minimize scar formation

Purse-string suture

This is a continuous suture that is placed around an area and tightened much like the drawstring on a bag.

Advantage

· Reduced wound size

· Minimize scarring

· Improve cosmetic outcome

Subcutaneous suture

The running subcutaneous suture is used to close the deep portion of surgical defects under moderate tension. It is used in place of buried dermal sutures in large wounds when a quick closure is desired.

Advantage

· Minimize scarring

· Improve wound healing

· Reduce the need for suture removal

PROCEDURE

• Identify the patient by hospital number

• Explain the procedure to the patient.

• Position the patient in a comfortable position on a bed

• Prepare all equipment required on a sterile field.

• Adjust the lighting.

• Expose the area to be sutured.

• Wash hands with skin antiseptic, rinse thoroughly and dry with sterile towel.

• Put on sterile gloves.

• Draw up local anesthetic and change to 24G needle.

• Clean area around and infiltrate with 1-% Lignocaine.

• Check effectiveness of anesthesia by gentle pressure from a needle.

• Clean wound and assess for foreign bodies or tendon or nerve damage.

• Assist the physician in suturing the wound by wound approximation and suture cutting.

• Apply dressing if necessary

• Discard the waste as per JMMCRI policy

• Document all relevant information in the medical record.

NM2802- REMOVAL OF STAPLER MANUAL

REMOVAL OF SUTURES AND STAPLER

INTRODUCTION

Sutures are threads used to sew body tissues together. Sutures used to attach tissues beneath the skin are often made of an absorbable material that disappears in several days. Skin sutures are made of a variety on non-absorbable materials such as silk, cotton, linen, wire, nylon, and Dacron.

Staples are made of metal and used for outer skin closure that causes less trauma to tissues than sutures and provides extra strength.

Sutures are removed when sufficient tensile strength has developed to hold the wound edges together during healing. The time frame varied on the patient’s age, nutritional status, and wound location.

PURPOSE

§ Prevent infection due to foreign material.

§ Provide aesthetic appearance.

ARTICLES

1. Suture removal kit (sterile)

a. Sterile straight scissors/stapler remover as indicated

b. Sterile forceps.

c. Antiseptic swab pockets.

2. Gauze pieces

3. Dressing Material

4. Antiseptic ointment

5. Clean gloves (1pair)

6. Sterile gauze (1pair)

7. Disinfectant

8. Kidney tray

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient by hospital number
Explain procedure to patient and describe the sensations that will be experienced such as pulling or slightly uncomfortable experience	Helps in obtaining cooperation of patient.
Use sterile technique infection.	Prevents spread of infection.
Check for physician’s order.	Act as a guideline for suture removal
Provide privacy.	Prevents embarrassment.
Wash hands.	Prevents risk of transmission of microorganisms.
Position the patient so that the dressing or incision is exposed.
Open sterile suture removal kit. Prepare a sterile field and place supplies on it.	Ensure aseptic technique
Don clean gloves
Remove and discard any dressing covering the wound.	Remove potentially contaminated materials.
Wash hands and don sterile gloves	Prevents infection
Clean sutures with spirit swabs moving from proximal to distal end. Discard swabs after wiping each surface once.	Cleaning and antiseptic action of alcohol removes surface microorganism from the wound site.
Removal of plain interrupted sutures .a. Place dry sterile gauze near the wound. b. Grasp the suture at the knot with forceps. c. Place the curved tip of the suture straight scissors under the suture as close to the skin as possible, either on the side opposite the knot and cut the suture. d. With the forceps, pull the suture out in one piece. Inspect the suture carefully to make sure that all suture materials are removed.	Suture material that is visible to the eyes is in contact with resident bacteria of the skin and must not be pulled beneath skin during removal. Suture material that is beneath the skin is considered free from bacteria.
Apply steri-strips on the wound or clean with betadine after removing sutures as ordered by physician.	Steri-trips hold the incision edges together and promote support in heating the wound
Instruct the patient about follow-up if wound discharge appears.
Place dressing on the incision if ordered	Provides a protective covering
Reposition the patient, wash and replace articles.	Gives neat appearance of the work area.
Discard the waste as per JMMCRI policy.
Wash hands	Prevents spread of infection
Document the number of sutures removed, the condition of the incision, evidence of dehiscence or infection if noticed, and time of the procedure in the medical record.	Act as a communication between staff members

Specific instructions

§ The patient is advised not to strain the part which may lead to wound dehiscence.

§ If wound discharge occurs, the patient should be instructed to inform the nurse.

§ Abdominal belts or binder may be applied on the abdomen sutures in obese patient to prevent wound dehiscence.

§ Assess the wound every shift.

Stapler removal

§ As directed on the package, gently position the sterile staple remover under the staple to be removed.

§ Firmly close the staple remover to straighten the staple ends (do not lift upward while disengaging staple ends.

§ Carefully lift the clips upward with the closed staple remover to remove them from incision line. It may be necessary to remove one end of the staple and then the other if it does not easily lift out.

§ Apply antiseptic ointment or dressing material as advised.

NM2803 - ASSISTING IN PLEURAL TAPPING THORACENTESIS

ASSIST IN THORACENTHESIS/ PLEURAL TAPPING

DEFINITION

Thoracentesis is the insertion of a needle into the pleural space to remove accumulated fluid and air using aseptic technique.

PURPOSE

To remove air and fluid from pleural cavity.

To decrease pressure on the lung tissue.

To aspirate pleural fluid for diagnostic studies.

To perform pleural biopsy.

EQUIPMENT

A pleural aspiration set containing

• Sponge holding forceps

• Syringe (5 mL ) and needle

• Artery Curved forceps

• Specimen bottles

• Gown, mask and gloves

• Syringe (20mL) with luer lock

• Aspiration needles (no16G)

• Small Bowl smalls

• Dissecting forceps

• Sterile dressing towels

• Cotton swabs, gauze pieces and straight scissors

• Scalpel blade

A clean tray containing

• Under pad

• Kidney tray and paper bag

• Antiseptic solution

• Lignocaine 2%

• Adhesive plaster and straight scissors

• Tincture benzoin

• Cardiac table

• Pillows

• Pulse oxymeter

• Oxygen cylinder with mask

PROCEDURE
NURSING ACTION	RATIONALE
Identify the patient and explain procedure to him and relatives. Explain that during procedure he may experience a sensation of deep pressure when fluid is aspirated.	Allays anxiety and wins cooperation.
Review the chest X-ray	X-ray shows localization of fluid and air in pleural cavity for determining puncture site.
Obtain an informed consent from patient.	Avoids risk of legal complications
Instruct patient that he should not move during procedure.	Any movement or coughing procedure can cause injury to vital organs or blood vessels.
Position the patient comfortably •Sitting on the edge of bed with the feet supported, arms and head on pillows over the cardiac table. •Lying on the unaffected side, with the bed elevated 30-40 degree if patient is unable to assume sitting position.	An upright position facilitates localization of fluid at the base of the chest.
Expose the chest. The physician determines the site for aspiration by visualizing chest X-ray and performing chest percussion. If air is be removed the site is usually in 2nd and 3rd intercostal space. If fluid is to be aspirated then site is usually in the8th and 9th intercostal space.	Fluid usually localizes at the base of the chest.
Clean the site with antiseptic solution and assist the physician in administering local anesthesia.	Reduces the risk of infection.
The physician introduces the thoracentesis needle. The sites are either midclavicular region of the 2nd intercostal space or mid axillary line of 5th intercostal space. Instruct the patient to hold his breath when needle is inserted.	Respiratory movement can cause risk of puncture to vital organs.
When needle is in pleural space, physician aspirates pleural fluid with syringe. Assist in collecting specimen in sterile containers. •A 20mL syringe with a three-way adapter is attached to needle. The tubing which leads to the receptacle is attached to the third port of the three-way adapter. •If a considerable quantity of fluid is to be removed, the needle is held in place on the chest wall.	The three way adapter helps in preventing air from entering the pleural cavity when large volumes of fluid are removed.
For therapeutic purpose usually 1000-1200mL of fluid is removed and for diagnostic purpose 30-60mL of fluid is removed. Encourage patient to remain to remain still during the procedure and monitor vital signs.
After needle is withdrawn, apply tincture benzoin seal and pressure dressing over the site.	Pressure dressing prevents risk of bleeding, leakage and infection site.
Position patient in bed with affected side up. He should remain in bed for 4-6 hours after procedure.	This position minimizes risk of possible fluid leakage.
Monitor vital signs every half an hour for 4-6 hours or till steady. Observe patient for complications such as shock, fainting, hypotension, rapid pulse, rapid respiration, uncontrolled cough and blood tinged frothy sputum. Check breath sounds in all lung fields.	Complications may occur because of accidental puncture of vital organs or blood vessels.
Record the procedure with total amount of fluid withdrawn, color, nature and sign of complication.
Send labeled specimen to laboratory
Instruct patient to do deep breathing and coughing exercises. Demonstrate and teach these exercises to patient.	Deep breathing and coughing promotes lung expansion
Have a chest X-ray if indicated
Wash articles used for thoracentesis in running water. Rinse, dry and send for autoclaving. Wear gloves while washing.
Discard the waste as per JMMCRI policy.
Document the relevant data in the medical record.

NM2804 – ASSISTING IN ABDOMINAL PARACENTESIS

DEFINITION

Paracentesis is the removal of fluid from peritoneal cavity through a small puncture made through the abdominal wall under sterile conditions.

PURPOSES

o To relieve pressure on the abdominal and chest organs due to ascites.

o To study chemical, bacteriological and cellular composition of peritoneal fluid for diagnosis of disease.

o To drain an exudate in peritonitis.

o To prepare for procedures like peritoneal dialysis.

o To remove fluid and instill air to create artificial pneumoperitoneum as a treatment for pulmonary tuberculosis affecting the base of the lungs.

SITE

Midway between the symphysis pubis and the umbilicus on the midline.

A point two-third along a line from the umbilicus to the anterior superior iliac spine.

ARTICLES

A sterile tray containing (abdominal tapping test)

o Sponge holding forceps

o 5mL syringe with needle.

o 20mL syringe with Leur-Lock.

o Three way adaptor and tubing.

o Trocar and cannula or aspiration needles.

o BP handle with blade.

o Suturing needles.

o Dissecting forceps.

o Specimen bottles.

o Sterile dressing towels or slits

o Artery curved forceps

o Gloves, gown and mask

o Cotton balls, gauze pieces and cotton pads

A clean tray containing (abdominal tapping test)

o Under pad

o Kidney tray.

o Antiseptic Solution

o Tincture benzoin.

o Lignocaine 2%.

o Apron

o Drainage receptacle.

o Pint measure.

o Measuring tape.

o IV set.

o IV bottle.

Additional Articles

o Back rest

o Low stool additional pillows.

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient and explain the procedure to the patient and relatives.	Wins confidence and cooperation from patient.
Measure abdominal girth and weight of the patient.	Provide baseline data.
Obtain informed consent.	Avoid legal problems.
Ask the patient to empty the bladder just before the procedure.	Prevents risk of injury to distended bladder.
Bring the patient to the edge of bed. Place him in Fowler’s position.	Promotes good body mechanics and fowler’s position helps in shifting fluid down.
Place sphygmomanometer cuff around patient’s arm to monitor BP during the procedure. Connect the patient to multipara monitor.	Hypotension may occur.
Wash hands and put on gloves.	Prevents transmission of infection.
Clean the area with antiseptic solution and assist the physician to administer local anesthesia. Drape patient with sterile towels.	Reduces risk of infection.
Assist the physician in inserting trocar and cannula into the abdomen below the umbilicus. Remove the trocar and attach the cannula to the tubing which reaches the receptacle which is placed on a low stool.	The greater the vertical distance between the needle and receptacle the greater will be the pull on the fluid thus the cavity is drained more quickly and the patient may develop hypotension.
Collect specimen ins sterile bottles.
After enough fluid is withdrawn (1-2 liters) remove the cannula and place a tincture benzoin seal, sterile dressing and pressure bandage over puncture site.	Pressure dressing and bandage helps to prevent leakage of fluid.
Check the patient’s general condition after procedure. Vital signs are checked every 15 minutes for 2 hours; then 30 minutes for 2 hours. Examine the dressing for any leakage.
Measure and describe the fluid collected and send the specimen to laboratory with labels and requisition forms.	To rule out bacteriological and chemical composition of fluid and to diagnose the disease.
Record the procedure, date, time, and amount of fluid collected, nature of fluid, color and general condition of patient during and after procedure. Include amount of fluid tapped in the patient’s 24 hours output.
Clean all articles using running water, rinse and dry it. Send the reusable item for sterilization.	Prevents cross infections.
Discard the waste as per JMMCRI policy.
Document all relevant data in the medical record.

NM2805 – ASSISTING IN LUMBAR PUNCTURE

Lumbar puncture also known as spinal tap, is an invasive procedure where a hollow needle is inserted into the space surrounding the subarachnoid space in the lower back to obtain samples of cerebrospinal fluid (CSF) for qualitative analysis. The procedure usually takes around 30-45 minutes.

PURPOSE

Measure cerebro spinal fluid (CSF) pressure.

Assist in diagnosis of suspected CNS infections (bacterial or viral meningitis, meningoencephalitis), intracranial subarachnoid hemorrhage, and some malignant disorders.

Evaluate and diagnosis demyelenating or inflammatory CNS processes such as Multiple Sclerosis, GuiIlan-Barre Syndrome, and Acute Disseminated Encephalomyelitis (ADEM).

Infuse medications which include spinal anesthesia before surgery, contrast material for diagnosing imaging such as CT-myelography , and chemotherapy drugs directly into the spinal canal.

Treat normal pressure hydrocephalus, cerebrospinal fistulas and idiopathic intracranial hypertension.

Placement of lumbar CSF drainage catheter.

CONTRAINDICATIONS

Increased intracranial pressure due to brain tumor.

Skin infection near the puncture site.

Severe degenerative vertebral joint

Severe coagulopathy.

EQUIPEMENT

PROCEDURE

Position the patient to patient position.

The patient is positioned on his side at the edge of the bed with his knees drawn up to his abdomen and chin tucked against his chest (fetal position) or sitting while leaning over a bedside table. When the patient is positioned supine, pillows are provided to support the spine on a horizontal plane.

Sterilize the site of insertion

The site is prepared with antiseptic solution (spirit, betadine, and spirit) and draped, and a local anesthetic is injected.

Insert the spinal needle.

The spinal needle is inserted in the midline between the spinous processes of the vertebrae (usually between the third fourth or the fourth and fifth lumbar vertebrae.

Remove the stylet from the needle.

The stylet is removed from the needle.CSF will drop out of the needle if it’s properly positioned. A stopcock and manometer are attached to the needle to measure the initial (opening) CSF pressure.

Collect specimen

Specimen are collected and placed in the appropriate containers.

Remove the needle

The needle is removed, seal the wound with tincture benzoin and a small sterile dressing is applied.

NURSING RESPONSIBILITY FOR LUMBAR PUNCTURE

Pre-procedure

• Identify the patient.

• Explain the procedure to the patient

• Obtain informed consent.

• Reinforce the diet.

o Advise the patient that fasting is not required.

• Promote comfort-

o Instruct the patient to empty the bladder and bowel before the procedure.

• Establish a baseline adjustment assessment data:

o Do the vital signs monitoring and neurologic assessment of the legs by assessing the patient’s movement, strength.

• Place the patient in a lateral decubitus position:

o Assist the patient assume decubitus position (fetal) position, near the side of the bed with the neck, hips, and knees drawn up to the chest.

o An alternative position is to have the patient sit on edge of the bed while leaning over a bedside table.

• Instruct to remain still :

o Explain that he or she must lie very still throughout the procedure. Any unnecessary movement may cause traumatic injury.

After the procedure

• Apply brief pressure to the puncture site:

o Pressure will be applied to avoid bleeding, and the site is covered by a small occlusive bleeding or band-aid.

• Place the patient flat on bed:

o The patient remains flat on bed for 4-6 hours depending on the physician. He or she may turn from side to side as long as the head is not elevated.

• Monitor vital signs, neurologic status, and intake and output :

o Take vital signs, measure intake and output, and assess neurologic status at least every 4 hours for 24 hours to allow further evaluation of the patient’s condition.

• Monitor the puncture site for signs of CSF leakage and drainage of blood:

o Signs of CSF leakage includes positional headaches, nausea and vomiting, neck stiffness, photophobia (sensitivity to light), sense of imbalance, tinnitus (ringing in the year), and phonophobia (sensitivity to sound)

• Encourage increased fluid intake:

o An increased amount of fluid intake (up to 3,000ml in 24 hours) will replace CSF removed during the lumbar puncture.

• Label and number the specimen tube correctly:

o Ensure all samples are properly labeled and sent to the laboratory immediately for further evaluations.

• Administer analgesia as ordered:

o Headaches after the procedure can last for a few hours or days and is usually treated with analgesics.

• Discard the waste as per JMMCRI policy

• Document all relevant information in the medical record.

NORMAL RESULTS

• Pressure: 70-180 mm H2O

• Appearance: CSF is normally clear and colorless.

• CSF total protein: 15-45 mg/dL.

• Gamma globulin: 3 to 12% of the total protein.

• CSF glucose: 50-80mg/dL.

• CSF cell count: normal CSF contains no red blood cells (RBCs), the white

• Blood cells (WBC) count IS 0-5 WBCs per micro liter (all mononuclear).

• CSF Chloride: 118 to130 mEq/L.

• Gram stain: no microorganism (bacteria, fungi, or virus) is present.

ABNORMAL RESULTS

◊ Pressure

o Increased intracranial pressure (ICP) occurs as a result of a tumor, hemorrhage, or trauma-induced edema.

o Decreased intracranial pressure (ICP) may reveal a spinal subarachnoid obstruction.

◊ Appearance

o Cloudy appearance indicating infection.

o Yellow to reddish appearance indicating spinal cord obstruction or intracranial hemorrhage.

o Brown to orange appearance indicating increased protein level or RBC breakdown.

◊ CSF Protein

o Increased protein indicating tumor, trauma, diabetes mellitus, or blood in cerebrospinal fluid (CSF).

o Decreased protein indicating rapid CSF production.

◊ Gamma Globulin

o Increased gamma globulin indicating a demyelinating disease such as multiple sclerosis, neurosyphilis, or guillan –barre syndrome.

◊ CSF glucose

o Increased glucose indicating high blood sugar (hyperglycemia).

o Decreased glucose indicating low blood sugar (hypoglycemia), bacterial or fungal infection, tuberculosis, or meningitis.

◊ CSF cell count

o Increased white blood cells in the CSF suggesting meningitis, tumor, abscess, acute infection, stroke, or demyelinating disease.

o Red blood cells in the CSF indicating bleeding into the spinal fluid or the result of a traumatic lumbar puncture.

◊ CSF chloride

o Decreased chloride indicating infected meninges.

◊ Gram stain:

o Gram-positive or gram-negative organism indicating bacterial meningitis.

COMPLICATIONS

§ Post-lumbar puncture headache.

§ Back pain

§ Pain or numbness

§ Bleeding

§ Brainstem herniation

NM2806 – ASSISTING IN EXTERNAL VENTRICULAR DRAIN

INTRODUCTION

The ventricular system produces CSF at approximately 500-600mL/day by the choroid plexus in the lateral ventricles. The CSF circulates around the brain and spinal cord and is then reabsorbed via the arachnoid villi.

The cranial vault contains brain tissue, blood and cerebrospinal fluid. As the volume of three components within the skull must remain equal, an increase in one component must be accompanies by decrease in another component. If there is not, an increase in intracranial pressure will occur.

External ventricular drain is a temporary system that allows drainage of cerebro spinal fluid (CSF) from the ventricles to an external closed system.

INDICATION

§ Hydrocephalus

§ Following surgery (tumor surgery), until the CSF circulation

§ To enable drainage of infected brain (meningitis)

§ In patients with severe head injury to provide both a means of measuring intracranial pressure (ICP) and allowing CSF drainage to treat raised ICP.

CONTRAINDICATION

§ Patient is receiving anticoagulation therapy

§ Scalp infection

ARTCLES

§ Bowl small

§ BP handle

§ Thumb forceps

§ Needle Holder

§ Artery curved forceps

§ Sponge Holder

§ Hand Towel

§ Drill set

§ Ventricular external CSF drainage system (contains one double chamber bag, bag anchoring panel, one 30 cm ID (inside diameter) 1.5 OD (outside diameter) 3.0 mm ventricular catheter with stylet, connector, trocar, catheter anchoring collar and connecting tube.)

§ Appropriate PPEs

§ Anesthetic Jelly (2%)

§ 5cc Syringe

§ 18 G needle

§ Surgical Blade 11

§ Suture Material

§ Antiseptic solution

§ Sterile Dry Gauze

§ Sterile Gauze Bandage

§ Sterile gauze pad

§ Scale

§ Adhesive material

§ Trimmers & clippers

PURPOSE

· Intracranial pressure monitoring

· Severe intracranial hypertension

PROCEDURE

§ Identify the patient by hospital number

§ Explain the procedure to the patient or his relatives.

§ Obtain the consent

§ Arrange the article near bedside.

§ The patient is maintained with head of bed elevated at 45⁰ in the supine position. The right frontal cerebral hemisphere is the preferred site of entry given its monodominance for language function in >90% of patients.

§ Remove the hair.

§ Clean the scalp sterile.

§ Assist the anesthetist to administer anesthesia medicine.

§ Assist the surgeon to locate the incision site.

§ After instillation of anesthesia a linear skin incision is made down to the bone and the periosteum is scraped.

§ A twist drill is used to penetrate the cranium in the trajectory determined for ventricular cannulation, and the pia and dura are pierced with scalpel.

§ The ventricular catheter is primed and passed no more than 7 cm, aiming in coronal plane toward the medical canthus of the ipsilateral eye and in the anteroposterior plane toward a point 1.5cm anterior to the ipsilateral tragus, toward ipsilateral Foramen of Monro.

§ Observe for the CSF flow after removal catheter stylet, it can be transduced to obtain an opening intracranial pressure.

§ The catheter is tunneled through the skin away from the point of entry through a separate incision, sutured securely in place, and then connected to an external drainage system.

POST-PROCEDURE CARE

§ Setting up the EVD device using an IV pole and leveling the device at the level specified in the physician order. The underlying pathology of patient is also taken consideration when determining the height of the collecting system.

§ Drainage can be continuous at a set level, fixed volume per desired time or as needed according to ICP elevations.

§ Adjust the height of EVD such that its pressure transducer is in line with the Foramen of Monro, which falls at the level of external auditory meatus of the ear in the supine position and at the mid sagittal line in the lateral position.

§ Adjust the drip chamber to the desired height level, before unclamping the chamber at this prescribed height, CSF will drain whenever the interventricular pressure exceeds that set by the height of the collection system. Flow ceases once the pressure equalizes between he CSF compartments in the brain and collection system.

§ The collection system must releveled whenever the patient changes position to avoid erroneous ICP reading and /or over or under drainage.

§ Spinal fluid samples are generally obtained through the proximal port (closest to the head) of the EVD collecting system and is performed using strict sterile technique due to risk of infection. When drawing the sample, aspiration should be very low (no more than 1ml/min) and if any resistance is met, the procedure should be aborted.

§ When medications are introduced into the EVD, such as tissue plasminogen activator for intraventricular hemorrhage or antibiotics for ventriculitis, the EVD should be clamped one hour after administration.

§ Monitor for signs and symptoms of intracranial hypertension (increase in the hourly output), aneurysm re-rupture (bright red bloody CSF) and infection (cloudiness of CSF).

§ Observe for the catheter its kinking or wet filter.

§ Assist in Extra ventricular drain Dressing must be observed for wet, soiled or loose.

§ Make sure the drain is kept opened unless indicated.

§ Ensure the patient head is elevated a minimum of 30 degrees and is supported in the midline position.

§ Maintain the collection system in upright position.

§ Routine change of catheter is not required.

§ Assess for the signs of infection such as redness, swelling or discharge at the exit site or an increased temperature.

§ Hourly documentation of CSF output and characteristics is mandatory. Also monitor vital signs and GRBS s

§ When transferring a patient make sure that the EVD is closed.

REMOVAL OF EVD

· Preparation

§ Verification of physician order

§ Perform imaging studies to evaluate the ventricular system.

§ Assess the neurological status and CSF output of the patient.

§ Prepare the necessary article and keep near the patient.

· Follow aseptic techniques

· Clamp the drain and observe the response of the patient to identify CSF production is stable.

· Remove the EVD catheter gentle out of the skull.

· Observe the insertion site and tight dressing to avoid

· Perform suturing or staplering if needed.

· Monitor for complications. Watch for patient neurological status and any leakage at the site.

· Maintain supine or semi recumbent position which helps to alleviate pain and discomfort.

· Document the date, time and post procedure neurological status of the patient in the medical record.

COMPLICATION

§ Infection

§ Hemorrhage

§ Misplacement

§ Blockage

§ Excess drainage

§ Fluid and electrolyte imbalance

§ Ventriculitis

§ Meningitis

§ Brain abscess

§ Subdural empyema

§ Accidental removal of EVD

NM2807 – ASSISTING IN VENESECTION

DEFINITION

Therapeutic venesection is a procedure where blood is removed from a patient’s circulation and has been shown to be beneficial with conditions such as Haemochromatosis, Polycythemia Vera and Porphyria Cutanea Tarda. Venesection is also used to treat post bone marrow transplant patients who are iron overloaded due to multiple blood transfusion.

INDICATION

Treatment of hematological disorders

Polycythemia Vera

Hemochromatosis

Porphyria Cutanea Tarda

Smokers polycythemia

EQUIPMENT

· Closed collection system

· 16-18G Cannula

· Antiseptic solution

· Alcohol swab

· Dry gauze

· Sterile Gloves

· Adhesive tape

· Underpad

· Pillow to position the site

PROCEDURE

· Identify the patient by hospital number and check doctor’s order.

· Explain the procedure and obtain the informed consent.

· Obtain vital signs – Blood pressure, pulse, temperature, respiration and oxygen saturations.

· Collect and send patient’s blood for hemoglobin, Sr.ferritin, BT, CT, &PTT and ascertain that the results.

· Hydrate the patient adequately.

· Provide privacy.

· Provide a well-lit area.

· Lie patient on a bed or chair and ensure they are comfortable.

· Perform hand hygiene at appropriate intervals throughout the procedure.

· Assemble equipment.

· Assess the vein and select a site, preferably in the antecubital fossa.

· Apply tourniquet (blood pressure cuff) 7-10 cm above antecubital fossa, ensure arterial flow is not obstructed by checking for presence of radial pulse.

· Place under pad under the site of puncture.

· Clean the site with antiseptic solution and wait for dry.

· Using aseptic non-touch technique, insert the venesection needle or IV cannula swiftly and smoothly at an angle of less than 30 degrees until flash back is obtained.

· Open clamp on venesection bag , and secure line with adhesive tape

· Venesection bag must be placed lower than the level of needle to ensure gravity flow into the venesection bag.

· Ask the patient to open and close fist gently every 10-12 seconds to promote blood flow.

· Do not pump fist (tightening and loosening of tourniquet) as it elevate levels of potassium and ionized calcium in the blood stream.

· Drape the patient appropriately.

· Communicate with the patient in-between the procedure.

· Once the required amount of blood has been removed, undo tourniquet, clamp venesection bag and withdraw needle gently, (unless patient requires post venesection hydration) applying pressure to the site using gauze. Advice the patient to avoid bending their arm as this increases the risk of developing a hematoma.

· Discard the waste as per JMMCRI policy.

· Monitor baseline parameters and observe for any complication.

· Document the relevant information in the medical record.

POST-PROCEDURE CARE

· Ask the patient to remain in the position for 15 minutes

· Inspect the venipuncture site for any hematoma.

· Ask the patient to sit up slowly, ensuring they are not dizzy or light –headed.

· Offer the patient something to drink.

COMPLICATION

· Hypovolaemia

· Vasovagal syncope

· Venous scarring

· Phlebitis‌

NM2810 – ASSISTING IN BONE MARROW ASPIRATION

DEFINITION

Assisting in obtaining a sample of bone marrow, aspirated from sternum/ileum/tibia using aseptic technique.

PURPOSE

• To diagnose hematological disorders.

• To follow the course of disease and patient's response to treatment.

• To diagnose disease such as primary metastatic tumors, infectious diseases and certain granulomas.

• To isolate bacteria and other pathogen by culture.

ARTICLE

• Syringe (20 cc-1, 10 cc-2,5 cc-2)

• Needles(no.18-2)

• Cannula -22

• Sterile gloves, Mask

• Dry Gauze

• Lignocaine2%

• Tincture benzoin solution

• Antiseptic solution

• Bouins Liquid

• EDTA tubes( violet)-5,Sample collection bottle with 2ml Bouins Liquid

• Slides -3

• Under pad

• Adhesive tape and straight scissors

• Kidney tray

Sterile pack containing:

• Towels

• Sponge holding forceps-1

• Bowl small medium-2

• Artery curved forceps -2

• Bone marrow aspiration needle with stylet

• Bone marrow biopsy needle (T shape/Jamshidi Needle)

• Sterile drapes.

CONTRA-INDICATION

• Disseminated intravascular coagulopathy

• Bleeding diathesis (hemophilia)ROCEDURE

PROCEDURE
NURSING ACTION	RATIONALE
Identify the patient by hospital number.
Check the physician’s order and nursing care plan and investigation reports like coagulation studies.	Obtain specific information/instructions
Ascertain that consent has been duly signed and fully understood by the patient	Fulfills performance of right procedure on right patient .allays fear and gains patient’s confidence and co-operation.
Collect and assemble equipment.
Ensure privacy. Shave the site, if necessary.	Avoids unnecessary embarrassment to the patient during the procedure.
Help patient into correct position Supine for sternal puncture Lateral position with upper knee flexed for iliac crest puncture. Prone position
Open small dressing pack and put sterile slide, and drape with sterile towels.
Assist physician to clean the site with solution and drape with sterile towels.	Reduces risk of infection.
Inform patient, that anesthetic will be injected and the site infiltrated.	Prepares patient to anticipate what he will be experiencing.
Continue to observe and reassure the patient as the physician punctures and aspirates the marrow.
Receive the syringe with bone marrow and collect specimen in various containers as indicated.	As per the physician’s order, approximately 3 to 5 bottles, each with a 3ml capacity, are to be collected.
Once the physician removes the needle, apply pressure over puncture site for 5-10 minutes using a sterile topical swab until the bleeding stops.	Minimizes bleeding and hematoma formation. Prolonged pressure, 5-10 minutes of pressure is required if the patient has low platelet count.
When bleeding stops, seal puncture site with tincture benzoin and apply small, firm dressing.	Avoid chances of oozing from puncture site.
Instruct patient not to wash or wet the area for 24 hours.	Provides an airtight seal over the puncture site and prevents entry of bacteria.
Make the patient comfortable. Instruct the patient may be mobile after 4-6 hours.
Remove and dispose of waste, wash and replace reusable articles.
Send specimen to laboratory with necessary data in the form and container properly labeled.
Document all relevant information in patient’s medical record.

PROCEDUREOCEDURE

POST PROCEDURAL CARE

Ø Keep patient in supine or lateral position

Ø Administer analgesics, if required.

Ø Monitor pulse and respiration every 30 minutes for 4-6 hours or until stable.

COMPLICATIONS

Bleeding

Infection

NM2811 - ASSISTING IN HYDROSTATIC REDUCTION PROCEDURE

Hydrostatic reduction is a procedure used to treat intussusception, a condition where part of intestine telescopes into another part. It involves using fluid such as normal saline to create pressure that pushes the telescoped bowel back into its normal position. The procedure is typically guided by ultrasound or fluoroscopy, allowing real-time monitoring of the reduction process.

Intussusception is the sliding of the one portion of intestine into the adjacent intestine which may lead to obstruction of the intestine leading to variable complaints, e.g. excessive crying with a short period of relief, vomiting, blood in stools.

ADVANTAGE

· No radiation is given to the child as compared to the fluoroscope guided method.

· Least invasive technique with high success rates hence avoiding the longer hospital stay, lesser complications and morbidity as compared to a child undergoing surgical intervention.

· Reduction of the bowel herniation is done under sonographic guidance allows a successful reduction.

ARTICLE

· Foley’s catheter 14 -16

· Warm normal saline (body temperature)

· Macro infusion set

· Syringe 10cc,20cc

· Under pad

· PPEs

CONTRA-INDICATION

· Peritonitis

· Abdominal distension

· Significant ascites

PREPARATION OF THE CHILD

· Explain the diagnosis, planned therapy, success rate and possibility of need for surgery to the bystanders and obtain an informed consent.

· Child should be kept nil per orally for 6 hours. Insert nasogastric tube if needed.

· Hydrate the child with parenteral normal saline.

· Assess the lab values of hemogram and serum electrolytes.

· Administer the prescribed sedatives.

PROCEDURE

· Identify the patient by hospital number

· Check physician’s order.

· Assemble all articles near child.

· Obtain diagnostic results before the procedure.

· Arrange the pre-warmed normal saline prior to the procedure.

· Obtain informed consent from responsible family member.

· Assist the child throughout the procedure.

· Warm saline is put into a cistern on a drip stand at a height of 1-1.5m above the child and connected to the Foley’s catheter.

· Insert the Foley’s catheter into the child’s rectum and start the inflow of warm saline.

· Press the child’s buttocks tight together to allow better sealing. By this method, a hydrostatic static pressure of up to 120mmHg within the lumen of large bowel can be achieved.

· By filling the colon with saline, the pressure of the accumulated saline pushes the small bowel loop backward, forcing it to slowly exit the colon through the ileocecal valve.

· The inflow of saline through ileocecal valve into the terminal ileum marks a successful reduction procedure.

· Discard the waste as per JMMCRI policy.

· Observe for any complications, Document the status of child and procedure details in the medical record.

FEATURES OF REDUCTION OF INTUSSUS CEPTION

· The child suddenly becomes comfortable and asymptomatic.

· Normal saline flows freely.

· Disappearance of the target sign (USG)

· Appearance of fluid filed small bowel loops (USG)

· Disappearance of the previously filled colonic loops (USG)

POST PROCEDURE CARE

· Make sure that the small bowel loops to fill well before stopping the infusion.

· Empty the fluid in the colon by gravity drainage of the infusion set.

· Deflate the Foley’s catheter bulb and remove after 5-10 minutes.

· Keep the child NPO for 6 hours to allow the bowel to rest and recover.

· Review ultrasound after 24 hours. If the child is irritable or blood is visible in the stool, repeat USG at the earliest.

· Once the child is stable and bowel sounds are present feeding can be gradually advanced to an age-appropriate diet.

· Frequent monitoring for signs of recurrence (abdominal pain, vomiting, and bloody stools) and complications (peritonitis, bowel perforation).

· Close monitoring of vital signs and serum electrolytes level and provide adequate rehydration and electrolyte supplementation.

· Administer prescribed antibiotics if infection suspected or prolonged reduction attempt.

DIFFICULT REDUCTION OR NO REDUCTION

· In difficult reduction, free flow of saline is absent and the child continue to strain severely.

· Features are persistence of mass at the same initial point or very slow movement of the mass.

REPEATED ATTEMPTS AT REDUCTION

· If some movements of the mass was present initially / mass reduced till the caecum initially, and the child has no abdominal signs.

· Repeat attempt at reduction can be done.

· Parenteral antibiotics are started.

· More than 3 attempts at hydrostatic reduction are not tried in single setting and proceeding with hydrostatic reduction for more than 6 hours is not advisable.

COMPLICATION

· Bowel perforation

· Recurrence

NM2812 – ASSISTING IN PR EXAMINATION

INTRODUCTION

Rectal examination consists of visual inspection of the perianal skin, digital palpation of the rectum, and assessment of neuromuscular function of the perineum. Rectal inspection involves both inspection and palpation.

INDICATION

Change in bowel habit

Prostate evaluation

Rectal bleeding

Urinary or fecal incontinence

A secondary approach to vaginal and cervical exam

CONTRAINDICATION

· Absence of anus

· Immunosuppressed patient

· Imperforate anus

· Prolapsed thrombosed internal hemorrhoids

· Stricture

· Severe anal pain

· Unwilling patient

· Acute abdomen

· Coagulopathy

· Major rectal trauma

· Postoperative anal surgery

· Recent acute myocardial infarction

· Valvular heart disease or prosthetic valves

EQUIPMENT

· Gloves

· Water soluble lubricant

· Lighting

· Soft tissues

· Kidney Tray

· Proctoscope

POSITION

Lithotomy position – The patient is supine with the legs drawn in toward the trunk and the knees allowed to fall out to side. (Anterior rectum).

Lateral decubitus/ Sim’s position – The patient lies on the left side with the buttocks near the edge of the examining table or bedside with the right knee and hip in slight flexion.

Proctologic position – knee chest position.

TECHNIQUE

Identify the patient.

Explain the procedure to the patient and clear the doubts.

Assemble the article near the patient

Position in the left lateral position. Flex the hips and knees and position the buttocks at the edge of the examining table.

Inspect the buttocks for fistulous tracts, the skin tags of haemorrhoids, excoriations, blood and rectal prolapse.

Part of the buttocks to expose anal verge and natal cleft and inspect the skin and anal margin.

Lubricate the examining index finger with a water-soluble gel and then press the examining finger against the posterior anal margin (6 o’clock).

The finger should slip into the anal canal, and the fingertip is directed posteriorly following the sacral curve.

Evaluate the anal tone by asking patients to squeeze the finger with their anal muscles.

Ask the patient to bear down to check for rectal prolapse and for proper descent of the perineum, the area between the thighs from the coccyx to the pubis. In normal individual the perineum lies about 2.5cm above the ischial tuberosity.

Early abscess or fistula formation can be evaluated by applying firm pressure on the ischial tuberosity.

To assess the neuromuscular integrity, scratch the side of the buttocks with gloved hand to elicit superficial anal reflex, a function of L₁ and L_2.Insert thelubricated index finger into the rectum to assess the anterior contraction of pubo rectalis muscle and the contraction of external anal sphincter.

Move the finger through 180⁰ , feeling the walls of the rectum. Examine the rectum to assess the entire circumference.

Rotate the finger to the 12 o’clock position, and palpate the anterior wall. Rotation facilitates further examination of the opposing walls of the rectum.

Assess the presence of masses, tenderness, haemorrhoids, fissures, ulcers and the colour and consistency of the stool. Prostate, its size, consistency and presence of nodule should be examined for.

In males, the prostrate will be palpated anteriorly.

In women, the cervix and a retroverted uterus may be felt with the tip of the finger.

Feels the walls of the rectum throughout the 360⁰.

Exam the prostate gland.

Normal size is 3.5cm wide and it should protrude about 1cm into the lumen.

The prostrate is normally rubbery and firm, with a smooth surface and a palpable sulcus between the left and right lobes.

It should not be tender and there should not be nodularity.

Massage the prostrate may reveal prostatic fluid at the urethral meatus.

On removal of finger, check the tipoff the glove for stool colour and the presence of blood.

Discard the waste as per JMMCRI policy.

Document all relevant information in the medical record

COMPLICATION

Discomfort and pain

Tearing of the perianal skin

Abrasion of hemorrhoidal tissue

Infection and bacteremia.

CLINICAL SIGNIFICANCE

External inspection

Anal fissures

Anal fistula

Genital warts

External haemorrhoids

Pilonidal sinus

Skin disease

Skin tags

Skin discolouration with crohn’s disease

Rectal prolapse

Internal inspection

Internal haemorrhoids

Rectal carcinoma

Rectal polyps

Tenderness with prostatitis or acute appendicitis

Malignant or inflammatory condition of the peritoneum with anterior palpation.

NM2813 – ASSISTING IN PV EXAMINATION

INTORDUCTION

Pelvic examination is performed to collect information about lower abdomen and external genitalia, vagina, cervix, uterus, adnexa, anus and rectum.

INDICATION

· Abnormal bleeding or discharge

· Pelvic pain

· Sexually transmitted disease

· Benign or malignant tumors

· Cysts

· Anatomic abnormalities

EQUIPMENT

· Cusco Speculum

· Artery Curved forceps

· Sterile Lubricant

· Cotton balls

· Cotton Applicator

· Dry Gauze

· Gloves

· Drape

· Kidney Tray

PREPARATION

· Identify the patient by hospital number

· Explain the procedure to the patient and clarify the doubts.

· Avoid having pelvic examination during menstruation.

· Avoid having sexual intercourse for at least 24 hours before pelvic exam

· Do not use vaginal douche, vaginal medicines or contraceptive creams for at least 24 hours before as these products may hide or wash away the abnormal cells.

STEPS

· The examining room must be clean and at comfortable temperature.

· Adequate lighting is important.

· Obtain the rapport of the patient and verbal consent for the procedure.

· Wash hands thoroughly.

· Place the patient in shod feet in stirrups.

· Wear gloves.

· Apply local anesthetic agent to the gloved hands to moisten it.

Inspection

· Look for the lower abdomen for gentle palpation of the lower abdomen for masses, tenderness, distension, hernias and incisions.

· Note should also be made of the pubic hair and its distribution as well as the amount and distribution of facial and axillary hair.

Palpation

· Keep the strongest hand on patient lower abdomen.

· With the index and middle fingers of the gloved hand, the external genitalia are inspected and palpated.

· Any lesion, such as a warty growth, a mass, an ulcer, or anything else, must be examined carefully.

· Notify the size of clitoris and the development of labia minora and majora.

· Inspect the skin between the posterior vaginal fourchette and the anus (perineal body).

· Inspect the Bartholin glands by keeping by keeping the index finger just inside the vaginal introitus. A normal Bartholin gland cannot be palpable.

· Palpate the anterior vaginal wall to the base of the bladder. Check for any pus formation at the external urethral meatus.

· Gently press downward on the posterior perineum and ask the patient to strain down and cough. Usually the cervix will not visible when the patient strains down.

· Palpate the medial border of the levator muscle which are not tender when palpated.

· Lubricate the speculum with local anesthetic agent.

· Insert the bivalve speculum over two fingers depressing the posterior perineum along the posterior vaginal wall.

· A cervical cytology smear should be taken.

· Inspect the cervix carefully. Look for erosion, eversion, cysts, polyps, lacerations, cervical enlargement, bleeding and menstrual discharge.

· Palpate the cervix with two fingers of the left hand in the vagina. Place the right hand on patient’s lower abdomen immediately above the symphysis pubis.

· Palpation of rectum and bladder is also done to check for any abnormalities.

· Discard the waste as per JMMCRI policy.

· Document all relevant information in the medical record.

COMPLICATION

· Chronic pelvic pain

NM2814 – ASSISTING IN NERVE BLOCKS

INTRODUCTION

A nerve block is an injection of medication close to a targeted nerve or group of nerves to provide temporary pain relief.

PURPOSE

The purpose of the nerve block is to inhibit impulse transmission distally in a nerve terminal, thus terminating the pain signal perceived by the cortex.

Types (based on the purpose)

Procedural anesthesia

Perioperative anesthesia

Diagnostic anesthesia

Types (based on duration)

Brief (hours)

Prolonged (months)

INDICATION

· Acute pain management of the extremities

· Anesthesia of the extremity for procedures

· Alternative to procedural sedation

· Post-operative pain management

· Chronic pain syndrome

· To reduce the inflammation and entrapment of a nerve or neuroma or “to break the cycle of pain”.

· Recalcitrant pain syndrome

· Alternative to opioids in certain patient populations (head injury patient , patient with concomitant mental status change, patients on buprenorphine

NERVES & AFFECTED EXTRIMITIES

Nerve	Location	Extremities Affected
Brachial plexus roots	Interscalane	Shoulder, upper arm, elbow , lower arm
Brachial plexus trunks	Supraclavicular	Upper arm, elbow, wrist and hand
Brachial plexus cords	Infraclavicular	Upper arm, elbow, wrist and hand
Brachial plexus branches	Axillary	Forearm, wrist, hand, and elbow including musculocutaneous nerve
Median nerve	Elbow	Hand, forearm
Radial nerve	Elbow	Hand, forearm
Ulnar nerve	Elbow	Hand, forearm
Femoral nerve	Femoral crease blocks	Anterior thigh, femur, knee,
Sciatic nerve	Subgluteal/anterior approach below the femoral crease	Posterior aspect of thigh and anterior, posterior, lateral lower leg, ankle and floor
Sciatic nerve	Popliteal	Anterior, lateral and posterior lower leg, ankle, and foot
Saphenous nerve, deep peroneal nerve, superficial peroneal nerve, posterior tibial nerve, and sural nerve	Ankle	Entire foot

PURPOSE OF NERVE BLOCK

NERVE BLOCK	LOCATION	PURPOSE
Celiac plexus	Anterior to the diaphragmatic crura and posterior to the stomach	Recalcitrant abdominal pain, pain associated with neoplastic conditions of pancreas, biliary tree, retroperitoneal structures,
Epidural	Between lumbar, thoracic, cervical vertebrae	Obstetrical anesthesia during labor and surgical anesthesia for thoracic, major intra-abdominal or spine surgeries.
Genicular nerve block	Knee joint	Chronic knee pain, total knee arthroplasty
Lumbar sympathetic nerve block	Between L2 –L3 vertebrae	Complex regional pain syndrome, lower limb painful ischemia, phantom limb pain, neuropathic pain
Occipital nerve block	One third of the distance from the occipital protuberance to the mastoid process.	Occipital neuralgia, migraine, post-dural puncture headache, cervicogenic headache, cluster head ache.
Pudendal nerve block	Lesser sciatic foramen, 1 cm inferior and medial relative to the attachment of the sacrospinous ligament to the ischial spine.	Perineal anesthesia during obstetric procedure, anorectal surgeries
Stellate ganglion block	Prevertebral fascia of the Longus colli muscle	Peripheral vascular disease, upper extremity embolism, complex regional pain syndrome of the head and upper limbs.
Trigeminal nerve block	Pterygopalatine or infratemporal fossa	Trigeminal neuralgia, migraine
Regional block
BLOCK	Nerves affected	Extremities
Interscalene block	C5-C7	Distal clavicle, Shoulder, Proximal humerus.
Axillary Block	Ventral primary rami of the C5-C8	Elbow, forearm, hand, Brachiobasilic fistula formation.
Femoral Block	Ventral rami of L2-L4	Anterior aspect of thigh
Pericapsular nerve group Block	Ventral rami of L2-L4	Hip and thigh (acetabular fracture, femoral neck or mid-shaft fracture, hip replacement, hip arthroscopy, knee surgery
Serratus anterior plane block	Cutaneous branches of the intercostal nerves, T2-T9	Anterolateral chest wall pain (rib fracture, thoracotomy)
Erector spinae plane block	Dorsal and ventral rami of spinal nerves, particularly those in the thoracic and abdominal regions.	Post-operative management thoracic, abdominal and breast surgeries.
Ankle block	Tibial, deep peroneal, superficial peroneal, sural, saphenous nerves
Median nerve block	Median nerve	Pain in the median nerve
Ulnar nerve block	Ulnar nerve	Pain in the ulnar nerve
Adductor canal block	Saphenous nerve, terminal branch of the femoral block	Pain relief knee surgery
Pop sciatica	Sciatic nerve in popliteal fossa	Pain relief to the lower leg and foot

Assessment

Complete history on the existence of underlying severe cardiac or pulmonary disease, opioid intolerance, pre-existing neurologic deficit, easy bleeding or bruising, and anticoagulation medications. The physical exam should direct focus to the sensory and motor function of the extremity undergoing blockade , evidence of coagulopathy (widespread bruising), evidence of systemic infection (fever or elevated white blood cell count) and infection at the site of the block (redness, swelling ,warmth).

Emergency airway equipment, resuscitation drugs (including lipid emulsion 20%), supplemental oxygen, and hemodynamic monitoring must be immediately available where blocks are performed.

Strict sterile technique should be maintained throughout the procedure.

Patient should be awake during the procedure so paresthesia can be reported easily and anesthetic injection can be redirected. An awake patient can report early symptom of local anesthetic systemic toxicity (tinnitus, circumoral numbness, and tachycardia with epinephrine) to avoid more serious complications that can occur a large volume local anesthetic injection (seizures, coma and cardiac collapse).

Equipment

· Dry gauze

· Antiseptic solution

· PPEs

· Local anesthetic agent

· Syringes (2ml, 10 ml)

· Needles (1, 1.5,3, 4.5 inch)

· Spinal introducer needle

· Blunt needle

· Radiofrequency needles with electrodes

· Catheter

· Contrast agent

· Neurolytic solution

PREPARATION OF PATIENT

· Identify the patient by hospital number

· Arrange the equipment

· Check for any history of allergy.

· Needles should be selected as per the location and purpose of injection to avoid nerve or tissue damage.

· Catheters material must be inert, nonirritating and supple enough to avoid cracking during placement.

· Fluoroscopy is essential to verify accurate needle placement and spread of opaque contrast material before injecting neuroltic agents.

· Obtain informed consent.

· Arrange the prescribed premedication.

· Arrange article for oxygen administration as it is the supplemental drug in sedatives and analgesics.

· Kind attention to the patient’s concern and situation will reduce the need for any of the preceding medication.

· Complete resuscitation facilities must be available, including equipment to provide positive pressure oxygen and suction, intubation equipment

· Assess the baseline level of consciousness, pulse oximetry and vital signs.

· Arrange the prescribed anesthetic agent and nerve localization articles.

CAUTION TO BE TAKEN IN DIFFERENT NERVE BLOCK

Spinal anesthesia (T1-T4)

· Patent IV line must be present.

· Continuous monitoring of blood pressure, ECG and respiration.

· Rate and depth of respiration must be monitored as cardio accelerator fibers may be blocked or venous return activation of the great vein and right arterial cardiac receptors are decreased.

· Patient are monitored for at least 12 hours after administration of the last dose of intrathecal opioids.

Epidural blockade

· Patent IV access

· Continuous monitoring of blood pressure, ECG and respiration.

· If the needle inadvertently enters the subarachnoid space (intended for epidural block), precautions are crucial to prevent complications such as managing the dosage and type of medication, continuous monitoring of vital signs and neurological function.

Sympathetic Ganglion Blocks

Stellate Ganglion Block

· Maintain patent IV line.

· Facilities to manage the seizure to be arranged.

· Resuscitation facility should be kept ready.

· Temperature probe on a fingertip of each hand before the block allows the measurement of a baseline temperature. An elevation of temperature on the blocked side indicates blocked sympathetic fibers.

· Fasting is advised before 8 hours of procedure to prevent aspiration and 4 hours after the procedure.

· Observe for elevated temperature on blocked site along with Bernard-Horner syndrome (myosis, ptosis, exophthalmos (sunken eye)).

Lumbar Sympathetic Ganglion Block

· Patent IV access is needed to administer sedatives or opioid analgesics in the event of an accidental intraspinal injection.

· Facilities to manage seizure.

· Fasting is advised 8 hours before the procedure to avoid aspiration.

· It is also important to assess the patient level of consciousness during the injection of local anesthesia and to maintain verbal contact after the block is complete.

· Monitor for lower extremity motor strength and sensation because of a possible somatic nerve block.

· Fluoroscopic assistance is needed to confirm proper needle placement.

· Monitor the baseline foot temperature. Longer acting local anesthetic may cause a temperature elevation up to 1.5⁰C.

Celiac Plexus Block

· Patent IV access.

· Continuous monitoring of blood pressure is recommended.as the sympathetic nervous system supply to the abdominal viscera is interrupted with this block, hypotension is common.

· Fluoroscopy is recommended after the procedure.

Somatic Nerve Block

· Nerve stimulator is recommended.

· Monitor for paresthesia as peripheral nerve injury may occur.

Intercostal Nerve Block

· Blood pressure, ECG, respiratory rate and level of consciousness should be monitored.

· Monitor for dyspnea and chest pain, pneumothorax may develop.

· Obtain a chest X-ray.

Lumbosacral Plexus and its Branches

Sciatic Nerve Block

· Minimal monitoring should include continuous regulation of blood pressure, ECG, and level of consciousness.

· Pulse oximeter should be used continuously if the patient receives any sedative or opioid medication.

· Peripheral nerve stimulator is recommended.

Head and Nerve Blocks

· Patent IV access

· Facilities for resuscitation

· Monitor blood pressure, ECG, respiratory rate and level of consciousness both throughout the block and during the recovery period.

POST BLOCKADE CARE

· Assess sensory level, proper body alignment, abdominal distention, urinary bladder distention, shock, bleeding and vital signs.

· Perform passive range of motion exercises every 30 minutes if not contraindicated.

· Assess the pain score and document.

COMPLICATION

· Block Failure

· Bleeding

· Infection

· Damage to surrounding structures

· Permanent nerve injury

· Intravascular uptake of local anesthetic resulting in systemic toxicity.

NM2901 - ASSIST IN ELECTROCONVULSIVE THERAPY

DEFINITION

Electroconvulsive therapy is a physical therapy, in which there is an application of electrical current to the temporal region of the brain to produce a grand mal type of seizure, for bringing about therapeutic effects.

INDICATION

• Major depressions

• Involutional melanholia

• Schizophreina

• Mania

• Postpartum depression

CONTRAINDICATIONS

• Increased intracranial pressure

• Recent myocardial infarction

• Cerebral hemorrhage

• Glaucoma

• History of cardiovascular disease

• Pregnancy

ARTICLES

• ECT machine, electrodes

• Multipara monitor

• Crash cart & Defibrillator

• Suction apparatus

• Oxygen cylinder

• Mouth gag and Tongue depressor

• Sterile syringes and needles

• IV stand

• Kidney Tray

• Elctroconductive gel

• Appropriate personal protective equipment

Preparation of ECT

NURSING ACTION	RATIONALE
Identify the patient and explain about procedure to the family and patient.	Helps in obtaining cooperation from patient.
Check if a thorough physical examination is completed which includes assessment of the cardiac, respiratory, skeletal system, etc. and investigations like routine blood and urine tests such as Hb% TC, DC, urine for glucose, albumin and X-ray.	These findings help rule out contraindication or risk of the patient for ECT
Get an informed consent from the nearest relative after explaining the purposes, method of treatment and risks involved.	Prevents legal problems. Explanations to the relatives will help them to overcome fear of therapy.
Patients should be kept nil per orally midnight, of the previous day.	Helps to prevents risk of vomiting and aspiration during and after the procedure.
Instruct the patient not to apply oil to head, on the day of ECT, and to wash hair using shampoo.	Oil is a bad conductor of electricity.
Remove all metallic articles from his/her body, e.g. watch, bangles, ring, safety pin, etc.	Prevents the electric current passing on unwanted areas, and causing burns since metal is a good conductor of electricity.
Remove artificial dentures.	Prevents dislodging and blocking of the respiratory passage.
Remove lipstick, nail polish or any other makeup.	These colors may mask any changes, if present, e.g. cyanosis.
Provide a loose gown
Administer medication as per physician’s order.	Enhances effectiveness of ECT.
Encourage patient to empty the bladder before entering treatment room.	Prevent soiling of bed due to relaxant effect of the drugs administered.
Give injection atropine 0.6mg IM or SC half to one hour prior to ECT as per order.	Blocks the vagal nerve thus decreases oropharyngeal secretions.
Check vital signs.	Helps to evaluate the condition of the patient.
Administer anxiolytics if ordered.	Relieves anxiety of patient.
Transfer the patient to the waiting room.

Assisting with administration of ECT

Shift the patient to ECT room.
Provide a well-padded bed with a pillow under lumbar curve. Patient can be placed in a supine position.	Well-padded bed helps to prevent injury.
Administer short acting anesthetic agents like thiopental as prescribed by physician.	Muscle relaxant and anesthetic are used to reduce violent convulsive attacks.
Place well-padded mouth gag or tongue depressor between the teeth.	Prevents tongue bite, injury to lips, and obstruction of airway caused by falling back of tongue.
Support the shoulder and arms lightly and restrain the knee joints firmly but gently.	Prevents fracture. Tight pressure may lead to fracture of femur or humerus.
Hyper extended the head with support to the chin.	Prevents jaw dislocation or fracture and facilitates patient airway.
Administer 100% oxygen by using face mask.	Helps the patient to overcome a phase of apnea after convulsions.
Provide electrodes dipped in gel for placement.	Gel is good conductor of electricity, thereby facilitates passing of current and production of convulsions.
Observe grandmal seizures. Initial tonic stage lasts for 10-15 seconds, followed by convulsions lasting for 25-30 seconds. Then there is a phase of muscular relaxation.	Ensures that treatment is successful and there are no sub shocks.
Do suction of mouth immediately.	Keeps away patient and prevents from aspiration pneumonia.
Restore respiration by giving oxygen by mask if required.	Prevents the patient from respiratory and cardiac complications.

POST-PROCEDURE CARE

Check and record vital signs.	Evaluates any respiratory of cardiac complications.
Put the side rails of bed up and place the patient on side lying position. Wipe the secretions.	Prevents falling of patient due to restlessness.
Transfer the patient to the recovery room when he can answer simple questions.	Ensures that patient has come out of the phase of unconsciousness.
Check vitals every 15 minutes till stable and record.	Helps o evaluate signs and symptoms of complications if any.
Encourage the patient to sleep for some time.	Helps to evaluate to overcome physical exhaustion.
Shift the patient to ward.
Reorient the patient to the ward, toilet, nurse’s station, etc.	Reorientation helps to overcome the state of confusion.
Check for any injury, pain, headache, etc.	Helps to detect any complications specially fracture.
Encourage the patient to drink clear tea followed by soft solids.	Meets the nutritional needs as they kept nil per orally from previous midnight.
Discard the waste as per the JMMCRI policy
Record relevant details in the medical record.	Evaluates the behavioral pattern after receiving ECT.

COMPLICATION

Impairment of memory.

Fracture and dislocations.

Headache, backache.

Painful mastication.

Injury to mouth and tongue.

Subshocks.

Confusion.

NM3001 - HEMODIALYSIS

DEFINITION

Haemodialysis is a method that is used to achieve the extracorporeal removal of waste products such as creatinine and urea and free water from the blood when the kidneys are in a state of renal failure. It is a mechanical process of removing waste products (toxic nitrogenous substances) and replacing essential substances by the process of diffusion and removal of excess water from the body by the process of osmosis by means of artificial kidney through semi-permeable membranes.

PURPOSE

Remove waste products from the blood. (Urea, k⁺)

Remove poisons or toxins from the blood. (Viper venom, leptospira, drug toxicity, naturopathy related problems)

Remove excess water.

Establish or maintain electrolyte imbalance.

ARTICLES

A clean tray

Hemodialysis machine

Dialysate solution in appropriate ratio

Dialyzer F₆

Blood tube

Transducer,

Surgical blade

IV fluid-1000ml (2)

IV set

D/S syringe 10cc-(3)

Inj. Heparin 10,000IU-1

Sterile gauze

Gloves – clean, non-sterile

A clean tray containing

Povidone iodine antiseptic solution

Alcohol swab

Adhesive tape

Kidney tray

Sterile tray containing

Sterile gauze piece

Straight scissors

AVF needle with appropriate gauge size.

Instruction to be noted

· Catheter care and accessing the patient’s circulation should be clean.

· Trained dialysis staff should only perform hemodialysis catheter dressing changes and catheter manipulations, which access the patient’s bloodstream.

· The catheter exit site should be examined at each hemodialysis treatment for signs of infections.

· Catheter exit site dressing should be changed at each hemodialysis treatment or once a weak and whenever needed.

· Use of dry gauze dressing combined with skin disinfection, using either chlorhexidine or povidone-iodine solution, followed by povidone iodine ointment or mupirocin ointment at the catheter site are recommended after catheter placement and at the end of each dialysis session.

· Manipulating catheter and accessing the patient’s bloodstream should be performed in a manner that minimizes contamination.

· During catheter connect and disconnect procedures, nurses, and patients should wear a surgical mask or face shield. Nurses should wear gloves during all connect and disconnect procedures.

PROCEDURE FOR ACCESSING CATHETER FOR HEMODIALYSIS

Check doctor’s order and identify the patient by hospital number.
Obtain the informed consent and endorse the consent at each repeat treatment. Monitor the validity period of the informed consent and follow JMMCRI policy for the fresh consent.
Collect the supplies. And arrange near bedside.	Collect the supplies ahead of time saves the time for the procedure
Explain the procedure to the patient. Position him such that the catheter lumens are best viewed.
Provide a comfortable bed.
Check weight of the patient and blood pressure. Observe the IJV site.
Wash hands.
Don clean gloves
Remove dressing over the jugular site.
Doff gloves
Wash hands
Don non-sterile gloves
Clean the jugular site with alcohol- povidone-iodine alcohol solution.
If the suture is missing, do suturing.
Observe for any infections, bleeding or clots on jugular site.
If there is any abnormality, inform the doctor, and do as per doctor’s order.
Do dressing over jugular site.
Doff the gloves
Wash hands
Remove the cap of the jugular catheter and put it in 1% sodium hypochlorite for removing the blood clots.
Open the pack, pour the antiseptic solution, and open the syringes into the pack.	Controls transmission of micro-organisms
Don the surgical mask and sterile / clean gloves	Control transmission of micro-organism
Cover the hub cap and joint with antiseptic solution and keep for few minutes before separating it. Place a clean or sterile towel under the catheter.	Reduces contamination
Aspirate 2ml from the cleaned port, clamp the lumen and leave the syringe there.	Ensure removal of clock solution. Placing the syringes in the ports avoid exposing the lumen to air.
Clean the second port similarly, aspirate 2ml and leave the syringe in place.
Load the 10cc syringes with normal saline.
Inject some normal saline into the first port and aspirate blood to check the patency of the lumen. Clamp the lumen. Leave the syringe there. Repeat the same for the next time.	Ensures that the lumen is patent before connecting the patient to the machine.
The syringes are removed as the dialysis lines are connected to the port	Minimize the exposure of lumen to air.
If the machine is ready, set ultra-filtration rate, time, flow rate, blood pump speed.
Using antiseptic method, clean the arterial access and arterial end of blood line connect it.
When the blood is going through the roller (machine pump) or passed through the heparin access, give inj.heparin 10,000IU
If the blood circulates and reaches the venous end stop the blood pump. Clamp the venous end, disinfect it with antiseptic solution and also venous access of the jugular catheter and connect it with blood line.
Release the clamp, blood pump speed decreases and start blood pump.
Check and observe for any abnormalities on venous site, like low venous alarm, or blood flow (such as sucking in blood line, or any clot in circuit) then gradually increases pump speed till the desired blood pump speed as per hospital policy or manufactories..
Check blood pressure
If the patient has any investigation before dialysis, collect blood from arterial access before connecting patient to the machine or if investigation ordered after starting hemodialysis, we can collect blood from blood lines(arterial side) after disinfecting area.
Doff gloves and wash hands.
Discard the waste as per JMMCRI policy
Document all relevant information in the medical record.

PROCEDURE TO DISCONNECT CATHETER LUMENS AT THE END OF DIALYSIS

NURSING ACTION	RATIONALE
Identify the patient by hospital number
Explain the procedure to the patient and clarify the doubts.
Collect the supplies: Sterile supplies, iodine 10%, chlorhexidine 2% or 70% alcohol, 10cc syringes-2, surgical mask, and normal saline in a sterile cup, lock solution in 2ml or 5ml syringe.	Collecting the supplies ahead of time saves the time for the procedure.
Rinse the catheter · Clamp arterial line first and saline flesh. · Connect IV line through connecter to the arterial line (100ml to 150ml of normal saline can be given to flush out the remaining blood in the arterial line.)	. A normal saline bolus may be required if the patient's blood pressure is low
Check the patient’s vital signs. If stable, clamp the catheter lumens and the dialysis lines.
Wash hands use hand rub. Open the pack, pour the antiseptic solution, and open the syringes into the pack.	Controls transmission of micro-organisms.
Don the surgical mask and sterile/ clean gloves.	Controls transmission of micro-organisms.
Use gauze impregnated with antiseptic to wipe one catheter port in circular motion	Friction facilitates removal of micro-organisms.
Place 10cc syringe with saline at the catheter port, open the clamp. Flush the lumen with 10ml of normal saline. Clamp the lumen and leave the syringe there. Repeat the procedure for the next lumen.	Ensures that the lumens are patent .placing the syringes in the ports avoid exposing the lumen to air.
Infuse the lock solution to the lumens according to the lumen size and close the clamps.	Use of lock solution reduces the risk of for clot formation within the lumen and infection.
Close the ports with sterile bunks.	Prevents contamination and entry of micro-organisms into the catheter lumen.
Cover the catheter lumens with sterile gauze or a clean pouch.	Projects the lumen from contamination and, dislodgement.
Discard the waste as per JMMCRI policy
Document all relevant information in the medical record.

Additional points noted in connection of AV fistula in hemodialysis

Check the AVF site, fistula thrill.

Wash hands, don non-sterile gloves.

Disinfect area of cannulation with alcohol-povidone iodine-alcohol solution.

Cannualate the catheter at a distance of 5cm

Usually lower site taken as arterial access, upper site taken as venous access.

Connect the fistula needle

Additional points noted in disconnecting hemodialysis from AV fistula.

Remove arterial access needle primarily .press the cannulate area gently with gauze piece. (Apply small pressure 1-2 min, check AVF site for thrill for 1-2 min) then tie it with IV belt.

Remove venous access needle.

Press cannulate area gently with gauze piece for 1-2 min.( apply small pressure for preventing fistula site bleeding

Apply IV belt

Observe for bleeding 1-2 min, check AVF site for thrill

Ask the patient to comfort of the fistula dressing (if it is too tight or painful).

Instruct the patient or bystander about loosening of IV belt.

Doff gloves, wash hands.

After 4-6 hours, slightly loosen IV belt.

After 8 hours-remove IV belt.

Instruct the patient not to strain AVF hand.

COMPLICATIONS

Bleeding.

Infection.

Air embolism.

Extravasations

NM3002 – PLASMAPHERESIS

DEFINITION

Plasmapheresis is a process that separates and removes the plasma component from a patient. When plasmapheresis is followed by replacement with fresh frozen infusion it is called plasma exchange.

TECHNIQUES

Plasmapheresis is performed by two fundamentally different techniques-either by centrifugation or by filtration.

In centrifugation -blood is pumped into the cell separator which spins around fast enough to create a centrifugal force that separates plasma from the rest of the blood.

In plasma filtration -blood is pumped by a machine through a plasma filter with small pores which will allow blood cells to pass through and plasma is sieved out and collected.

INDICATIONS

Category-1

Acute inflammatory demyelinating polyneuropathy (Guillain-Barre Syndrome)

Chronic inflammatory demyelinating polyradiculoneuropathy.

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections.

Sydenham’s chorea

Multiple sclerosis

Myasthenia gravis

Thrombotic thrombocytopenic purpura.

Atypical hemolytic uremic syndrome.

Thrombotic microangiopathy

Wilson’s disease with hepatic failure.

Type-1 RPGN anti-glomerular basement membrane disease

Category-11

Catastrophic anti phospholipid syndrome.

Severe systemic lupus erythamatosus.

ABO incompatable heart and kidney transplantation.

Category-111

Acute liver failure

DIC due to sepsis with organ failure

Type 11RPGN: immune complex rapidly progressive glomerulonephritis.

Category-1V

Typical hemolytic uraemic syndrome.

Systematic lupus erythematosus associated Nephritis.

ARTICLE

Heparin 1000IU/ml

Syringes 10cc and 20cc

Normal saline flush

Spirit swab

One pair of sterile and unsterile gloves

Sterile cotton pad.

GENERAL INSTRUCTION

Heparin protocol for plasmapheresis

For bolus administration- 80IU/Kg

Maintenance dose-20 IU/Kg

If platelet is less than 1 lac or INR value is above 2, avoid use of heparin and use 0.9% normal saline at 250ml/hour infusion.

PROCEDURE

NURSING ACTION	RATIONALE
Identify the patient by hospital number.
Explain the procedure to the patient.
Patient requires a double lumen vascular catheter (vasa Cath) for the procedure.
Confirm that catheter is position using a chest x ray and ensure that catheter is patent before procedure.
Place the patient in a comfortable position. ( usually supine position)
Monitor heart rate, blood pressure, oxygen saturation before start of procedure. If there is hypotension start on vasopressin medication.
Follow standard aseptic precautions.
Connect the blood tubing and flush with 0.9% normal saline for de airing the tubing. Ensure that there is no air in tubing before connecting to vascular catheter.
Heparin is started as an infusion to prevent coagulation of blood in the tubing. If there is any contraindication for heparin, use 0.9% normal saline at 250ml/hour infusion.
Collect the plasma in uro bag.
Monitor for complication.
Discard the waste as per JMMCRI policy.
Document all relevant information in the medical record.

COMPLICATION

¨ Hypotension

¨ Stock

¨ Cardiac arrest

¨ Blurring of vision

¨ Bradycardia

¨ Arrythmias

¨ Hypoglycemia

¨ Parasthesia

NM3003 – PREPARATION OF ARTERIOVENOUS FISTULA & CARE

DEFINITION

Arteriovenous fistula (AVF) is a surgically created fistula between an artery and an adjacent vein, which serves as an access for hemodialysis.

BENEFITS

Allow high blood flow so that the largest amount of blood can pass through the dialyzer.

Lasts longer than other types of access.

Is less likely to get infected or cause blood clots than other types of access.

The correct technique used for accessing fistula and reduces the risk for complications.

INDICATION

To carry out Hemodialysis in a patient with:

Chronic kidney disease (CKD)

Acute kidney disease

Drug toxicities

Acute complications due to CKD

ARTICLE

Sterile dressing pack,

Sterile gloves

10cc syringe

Povidone iodine solution

Alcohol swab

Cotton balls

Normal saline in a sterile bowl small

Cannulas of appropriate size.(17G)

Heparin in prescribed dilution.

Under pad

Sterile Towel

Bowl small medium

Towel clip

GENERAL INSTRUCTION

· Identify the patient & check physician order.

· Explain the procedure to the patient

· Check vital signs.

· Get informed consent.

· Prepare the articles.

PROCEDURE

· Skin Preparation

o Wash hands.

o Advice the patient to wash access site using an antibacterial soap or scrub and water.

o Position the patient’s hand comfortably and expose the fistula site.

o Spread under pad below the fistula site.

o Locate and palpate the needle cannulation sites prior to skin preparation.

o Cleanse the skin by applying 70 % alcohol and/or 10% povidone iodine in circular motion.

· Technique for AV fistula/ AV graft cannulation

o Skin preparation, pull skin taut in opposite direction of needle insertion

o select approximately 45⁰ angle of insertion for Arteriovenous graft and approximately 25^oangle of Arteriovenous fistula

o Once the vessel has been penetrated there are basically three methods employed in exact practice:

o Advance the needle slowly with cutting edge facing top of vessel and do not rotate.

o Immediately rotate the axis of needle 180⁰ and advance slowly with cutting edge facing bottom of vessel.

o Advance the needle to desired position, then rotate the axis 180⁰

o Tape the needle at the same angle or one similar to the angle

o Remove needle at the same angle or angle similar to angle of insertion, and never apply pressure before needle is completely.

o Apply folded dry gauze at the site as soon as the needle is removed and apply firm pressure before and tie tightly.

o Discard the waste as per JMMCRI policy.

o Document the assessment finding of accesses site, ease of cannulation and the time taken for hemostasis after removal of cannula in the medical record.

AFTER CARE

· Monitor the cannulation site every 30 minutes for placement of needles or any bulging.

· Instruct the patient to report any bleeding from fistula site after removal of needles and advise to apply firm pressure over the area in case of bleeding.

· Check radial pulse, color, warmth, and sensitivity of affected site.

· Elevate access arm.

· Educate the patient regarding following;

1. Avoid blood pressure monitoring and blood investigation on the fistula arm.

2. Avoid infections and infusions on fistula arm.

3. Avoid tight or restrictive clothing and ornaments.

4. Avoid sleeping on the fistula arm.

5. Do not use sharp objects near the fistula (razors)

6. Avoid carrying heavy objects by fistula arm.

7. Check the thrill

8. Avoid exposure to extreme cold and hot.

9. Keep the dressing for at least 6-8 hours.

10. Assess the site for bleeding thrill after removal of dressing

NM3005 – REPROCESSING OF DIALYZER AND BLOODLINE

INTRODUCTION

The main objective of reprocessing dialyzers is lowering cost; this should not compromise the quality of dialysis and safety of patients.

Another concern is the relative environmental load of reprocessing chemicals versus that of discarded dialyzers.

MANUAL REPROCESSING

Blood line

· Return the blood using the machine’s blood pump and 0.9% normal saline.

· Air should not be allowed to enter the blood tubing or the dialyzer. It is advisable to then add around 1000U of heparin to the saline bottle and further fill the circuit after disconnecting it completely from the patient.

· Following this step, the arterial and venous tubing are joined with a universal connector and heparinized saline is circuited in the extracorporeal circuit for about 5 min.

· Remove dialyzer and tubing from the machine and take to the reprocessing area in a covered tray to avoid blood spills.

· The tubing are disconnected and the blood compartment of the dialyzer is connected to the RO water source.

· The blood compartment is rinsed with RO water till the effluent is clear. Clean by instilling 0.25% hypochlorite into the blood compartment till it is completely filled and allowed to stay for 20-30 minutes. If clot present repeat the cleaning by 0.25%sodium hypochlorite solution.

· Immediately rinse out of the cleaning agent from the blood compartment is recommended.

Dialyzer cleaning

· Wash the dialyzer with RO water and instill hydrogen peroxide 6% and paracetic acid-base agents (renalin) 2% in the dialysate compartment and backwashing or reverse Ultra- filtration should be started after 30 minutes. If clot present repeat the cleaning by 0.25%sodium hypochlorite solution.

· Paracetic acid-bases agents (renalin) 2% be instilled in the dialysate compartment till next use (minimum 24 hours).

· Inspect the dialyzer for a large number (>20%) of discolored fibers (muddy color), large clots in the header, generalized blackening, change in color, or esthetically unpleasing appearance. If the clots in the headers appear small and friable, the header may be removed from the dialyzer to be cleaned separately.

· Rinse out the cleaning agents with water.

· Backwashing or reverse Ultrafiltration- the one end of the blood compartment is connected to the water supply, which is turned off, whereas the other end is left open.

· The one end of the dialysate compartment is capped, whereas the other end is connected to a water supply with a pressure of 1-1.3 bar through a Hansen’s connector.

· The water should enter the dialysate compartment and exit through the blood compartment.

· This step must be carried out for at least 15 minutes with periodic 1-2 min rinsing of the blood compartment.

· The direction of flow should be reversed at 5-min intervals.

· Discard the waste as per JMMCRI policy

· Document all relevant information including the number of reuse in the medical record.

NM3102 – FEEDING INFANTS WITH CLEFT LIP & PALATE

DEFINITION

Feeding babies with cleft lip and palate using appropriate devices

PURPOSES

To meet nutritional needs of the baby

To prevent complications such as aspiration

GENERAL INSTRUCTIONS

Give frequent feeds to keep palate from drying.

Administer gavage feeding if nipple feeding is to be delayed.

If sucking is permitted, use of soft nipple with crosscut to facilitate feeding. Nipples can be softened by boiling them.

If sucking is ineffective due to inability to create a vacuum, Try alternate oral feeding methods.

a) Feeding devices include:

Syringe feeders, Crosscut nipples

Rose cleft palate nurser

Haberman feeder

Palatal obturator.

b) Avoid enlarging nipple holes as the infant’s inability to control the flow of milk will result in choking. Crosscut nipples allow milk to flow when infant’s squeezes the crosscut open.

c) Using a squeezable bottle or plastic liner can be helpful by applying rhythmic pressure along with the infant’s normal sucking and swallowing.

d) When using rubber tipped asepto syringe or dropper; the rubber extension should be long enough to extend into back of mouth to prevent regurgitation through the nose. Direct tip to side of mouth, and feed slowly.

e) Teach the parents ESSR method of feeding.

E- Avoid enlarging nipple

S-Stimulate the suck reflex

S-Swallow

R-Rest to allow baby to finish swallowing what has been placed I n the mouth.

f) The infant to be fed in an upright position and the flow of milk should be directed to one side of mouth to avoid choking.

Nursing action	Rationale
Identify the patient by hospital number.
Explain procedure to mother and encourage mother to clear her doubts.	Helps mother to acquire knowledge about feeding technique.
Assess for sucking and swallowing reflex of the baby.	Helps to choose the feeding method.
Make mother to sit in comfortable position with the baby held in upright position.	Decreases possibility of fluid being aspirated or returned through the nose or back to the auditory canal.
Place the nipple (teat) angled to the side of mouth away from the cleft.	Prevents aspiration
Feed slowly over approximately 15 to 30 minutes.	Feedings longer than 45 minutes expends too many calories and tries the infant.
Give small frequent feeds and burp after each feeding.	Decreases amount of air swallowed.
Avoid repeated removal of nipple due to fear of choking	Frustrate the infant causing crying which increases chances of aspiration.
Feed infant before he becomes too hungry.	Infant gets agitated when hungry and feeding becomes a problem.
Give adequate amount of water after each feeding.
Position the baby on side after feeding.	Prevents regurgitation.
Discard the waste as per JMMCRI policy.
Document time, feed, amount and baby’s tolerance to given feed in medical records.	Acts as a means of communication between staff members.

SPECIAL CONSIDERATIONS

Cup and spoon

Paladai (feeder with beaked tip)

Feeder with compressible plastic sides which can be squeezed to help eject milk.

PREPARED BY	VERIFIED BY	APPROVED BY	ISSUED BY
Assistant Nursing Superintendent Nurses Education	Assistant Director	Director	Quality Coordinator