Basic Nursing Arts

LECTURE NOTES
For Nursing Students
Basic Nursing Arts

Abraham Alano, B.Sc., M.P.H.
Hawassa University
In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,
the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education
August 2006
Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.
Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter
Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.
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Limited permission is granted free of charge to print or photocopy all pages of this
publication for educational, not-for-profit use by health care workers, students or
faculty. All copies must retain all author credits and copyright notices included in the
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©2006 by Abraham Alano
All rights reserved. Except as expressly provided above, no part of this publication may
be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system,
without written permission of the author or authors.
This material is intended for educational use only by practicing health care workers or
students and faculty in a health care field.
PREFACE
Nursing is core part in health service delivery system in which health

promotion, disease prevention, curative and rehabilitative health strategies
are applied. The skill of basic nursing art for the beginning public heath
nurse is of paramount important. The purpose of preparing this lecture
note is to equip public health nurses with basic nursing skills, which will
enable them to dispatch their responsibility as well as to develop uniformity
among Ethiopian Public Health Nurse Training Higher Institutions.
The lecture note contains basic selected topics, which are relevant to their
scope. It is well known that no nursing service can be provided with out
basic skills of nursing art. For public health nurse to provide health service
at different settings; hospital, health center, health post and at the
community level, the course is very essential.
The lecture note is therefore organized in logical manner that students can
learn from simpler to the complex. It is divided in to units and sub topics.
Important abbreviations and glossaries have been included in order to
facilitate teaching learning processes. On top of that learning objectives
are clearly stated to indicate the required outcomes. Trial is made to give
some scientific explanation for procedure and some relevant study
questions are prepared to each unit to aid students understand the
subject.
ACKNOWLEDGMENTS
My deepest appreciation is to Carter Center and Professor Dennis

Carlson, senior consultant of the Center for his undivided and genuine
support starting from initiation of the lecture note preparation, provision of
materials and technical advise.
I also extend many thanks to colleagues

from sisterly institutions and
staff
of our department for their valuable
comments and criticism, other wise
the lecture note would have not been
shaped.
Similarly, my felt thanks is totive
suppor
staff of Carter Center, Ato Aklilu
Mulugetta for his devoted support through the preparation of this lecture
not.
eLast but not least, I thank all our College authorities for permission to
work
on this lecture note besidesine
theactivities of the college.
rout
ABBREVATIONS & SYMBOLS
A.C. Before meal (ante cibum)

ACTH Adreno cortico trophic hormone
AD. As desired
AM. Morning
AMALG Amalgam filling
AMA Against medical advice
A and P Auscultation and percussion
APC Aspirin, Phenacetine & caffeine
AQ Aqueous
BID Twice a day (bis in die)
B.M Bowel movement
B.M.R. Basal metabolic rate
B.P Blood pressure
B.R.P. Bathroom privilege
BUN Blood urea nitrogen
o
C Centigrade
C.B. C Complete blood count
CC Cubic centimeter
C.N. S. Central nervous system
Co 2 Carbon dioxide
C.S. F. Cerebro- spinal fluid
D and C Dilatation and Curettage
D/NS Dextrose in normal saline
DPT Diphtheria, pertusis, tetanus
D/W Dextrose in water
Dx Diagnosis
EEG Electro encephalogram
E.E.N.T. Eye, ear, nose, throat
ECG Electrocardiogram
oF Fahrenheit
F.B.S. Fasting blood sugar
F.H.B. Fetal heartbeat
G.I. Gastro intestinal
G or Gm Gram
gr. Grain
gt. Drop (gutte)
gtt. Drops
G.U. Genito urinary
GYN. Gynecology
HCL Hydrochloric acid
Hb Hemoglobin
HS At bed- time (hours of sleep)
H 2o Water
I.V. Intravenous
I.V.P Intravenous pyelogram
KI. Potassium iodide
L. P Lumbar puncture
NaCl Sodium Chloride
NOCTE At night
N.P.O. Nothing by mouth (nothing by os)
O.P.D. Out Patient Department
O.R. Operating room
PM After noon
PRN As needed, when
necessary
Pt. Patient
Q. Every
Q.D. Every Day
Q.H. Every Hour
Q.I.D. Four times a day
Q.N. Every night
Q.O.D. Every other day
R.B.C. Red blood count or red blood
cell
Rh. Rhesus factor
Rx Prescription, take
Sol. Solution
SOS If necessary
STAT Immediately -at once
S.C Subcutaneous
T. I.D Three times a day
T.P.R. Temperature, pulse, respiration
Tsp Teaspoon, tablespoon
U.R. Upper right
WBC White blood cells
Wt. Weight
U.R.Q. Upper right quadrant
U.L.Q. Upper lower quadrant
UTI Urinary tract Infection
Basic Nursing Art
1
Contents
Preface i
Acknowledgement ii
Abbreviation iii
Unit One
Introductiion 1
Unit Two
Care of the patient unit and equipment 4
Unit Three
Bed Making 22
Unit Four
General care of the patient 29
Unit Five
Observation and laboratory diagnosis 57
Unit Six
Cold and heat application 89
Unit Seven
Elimination of Gastro Intestinal And Urinary Tract 92
Unit Eight
Medication Administration 111
Unit Nine
Wound care 138
Unit Ten
Pre & postoperative nursing care 151
Unit Eleven
Post- mortem care 162
Glossary 165 References 169
Basic Nursing Art 1
UNIT ONE
INTRODUCTION
Nursing
Definition:
It is assisting the individual, sick or well in the performance of those
activities contributing to health or its recovery (to peaceful death) that he
will perform unaided, if he had the necessary strength, will or knowledge
and to do this in such a way as to help him gain independence as rapidly
as possible (Virginia Henderson 1960).
Nursing is the art and science involves working with individual, families,
and communities to promote wellness of body, mind, and spirit. It is a
dynamic, therapeutic and educational process that serves to meet the
health needs of the society, including its most vulnerable members.
Historical Background of Nursing

In the early ages, much of the practice of medicine was integrated with
religious practices. Before the development of modern nursing, women
of nomadic tribes performed nursing duties, such as helping the very
young, the old, and the sick, care-dwelling mothers practiced the nursing
of their time.
As human needs expanded, nursing development broadened; its interest

and functions through the social climates created by religious ideologies,
economics, industrial revolutions, wars, crusades, and education. In this
way modern nursing was born.
The intellectual revolution of the 18th and 19th centuries led to a scientific
revolution. The dynamic change in economic and political situations also
influenced every corner of human development including nursing. It was
during the time of Florence Nightingale that modern nursing developed.
She greatly modified the tradition of nursing that existed before her era.
She also contributed to the definition of nursing " to put the patient in best
possible way for nature to act." Since her time modern nursing
development has rapidly occurred in many parts of the world.
History of Nursing in Ethiopia

Basic Nursing Art 2
Even though Ethiopia is one of the oldest countries in the world,
introduction of modern medicine was very late. Health care of
communities and families was by Hakim (wogesha or traditional healers).
Around 1866 missionaries came to Eritrea, (one of the former provinces
of Ethiopia) and started to provide medical care for very few members of
the society. In 1908 Minlik II hospital was established in the capital of
Ethiopia. The hospital was equipped and staffed by Russians.
Later hospital building was continued which raised the need to train
health auxiliaries and nurses. In 1949 the Ethiopian Red Cross, School of
Nursing was established at Hailesellasie I hospital in Addis Ababa. The
training was given for three years. In 1954 HailesellasieI Public Health
College was established in Gondar to train health officer, community
health nurses and sanitarians.
During the regimen of 'Dergue', the former bedside and community health
nursing training was changed to comprehensive nursing. An additional
higher health professional training institution was also established in 1983
In Jimma.
After the overthrown of the Dergue, the transitional government of

Ethiopia developed a health policy that emphasizes health promotion,
diseases prevention, and curative and rehabilitative health service with
priority to the rural societies. As the result of the policy the training of
public health nursing at the diploma level came in to existence since
1995. Additional public health higher training institutions were established
at Dilla and Alemaya in 1996. The outputs of these training institutions
are providing services all over the country.
UNIT TWO
CARE OF THE PATIENT UNIT AND EQUIPMENT
Learning Objective
At completion of this unit the learner will be able to:
• State the general instruction for nursing procedures.
• Define patient and patient unit.
• Take care of patient unit and equipment in health care facilities
• Admit and discharge patients according to agency policy
Basic Nursing Art 3
• Assist helpless patients to move and maintain normal body
alignment
General Instructions for All Nursing Procedures

1. Wash your hands before and after any procedure.
2. Explain procedure to patient before you start.
3. Close doors and windows before you start some procedures like
bed bath and back care.
4. Do not expose the patient unnecessarily.

5. When ever possible give privacy to all patients according to the
procedure.
6. Assemble necessary equipment before starting the procedure.

7. After completion of a procedure, observe the patient reaction to the
procedure, take care of all used equipment and return to their
proper place.
8. Record the procedure at the end.
A. Care of Patient Unit
I. THE PATIENT UNIT
Definition:
Patient: A Latin word meaning to suffer or to bear.
- Is a person who is waiting for or undergoing medical
treatment and care.
A. Patient Care Unit: is the space where the patient is

accommodated in hospital and consists of the bed, an over bed
table, a bedside table, and possibly a chair. There may also be
closet space or drawer.
The patient unit is of three types:

1. Private room – is a room in which only one patient be
admitted
2. Semi private room – is a patient unit which can

accommodate two patients
Basic Nursing Art 4
3. Ward- is a room, which can receive three or more patients.
Consists of a hospital bed, bed side stand, over bed table,
chair, overhead light, suction and oxygen, electrical outlets,
sphygmomanometer, a nurses call light, waste container and
bed side table.
B. Hospital Bed
• Gatch bed: a manual bed which requires the use of hand
racks or foot pedals to manipulate the bed into desired
positions i.e. to elevate the head or the foot of the bed
⇒ Most commonly found in Ethiopia hospitals

⇒ Are less expensive and free of safety hazard
⇒ Handles should be positioned under the bed when not in
use
C. Side rails
• Half rails – run only half the length of the bed, are meant to
prevent client falls
• It should be attached to both sides of the bed

♦ Rails
– Full rails – run the length of the bed
– Half rails _ run only half the length of the bed and
commonly attached to the pediatrics bed.
D. Bed Side Stand

• Is a small cabinet that generally consists of a drawer and a
cupboard area with shelves
• Used to store the utensils needed for clients care. Includes

the washbasin (bath basin, emesis (kidney) basin, bed pan
and urinal
• Has a towel rack on either sides or along the back

• Is best for storing personal items that are desired near by or
that will be used frequently E.g. soap, shampoo, lotion etc
E. Over Bed Table

• The height is adjustable
• Can be positioned and consists of a rectangular, flat surface
supported by a side bar attached to a wide base on wheels
• Along side or over the bed or over a chair

Basic Nursing Art 5
• Used for holding the tray during meals, or care items when
completing personal hygiene
F. The Chair
• Most basic care units have at least one chair located near
the bedside
• For the use of the client, a visitor, or a care provider
G. Overhead Light (examination light)
• Is usually placed at the head of the bed, attached to either
the wall or the ceiling
• A movable lamp may also be used
• Useful for the client for reading or doing close work
• Important for the nurse during assessment
H. Suction and Oxygen Outlets
• Suction is a vacuum created in a tube that is used to pull

(evacuate)fluidsfromthe bodyE.g. to clearrespiratory
mucus or fluids
• Oxygen is one of the gases frequently used for health care

today. Oxygen is derived through a tube.
I. Electrical Outlets
• Almost always available in the was at the head of the bed
J. Sphygmomanometer
• The blood pressure assess

ment tool, has two types:
1. An aneroid
2. Mercury,which is frequentlyused during nursing
assessment.
K. Call Light
• Used for client’sto maintainconstantcontactwithcare

providers
II. Care of Patient Unit
• Nursing staffs are not responsible for actual cleaning of dust and
other dirty materials from hospital. However, it is the
staff nurses' duty to supervise the cleaner who perform this
job.
Basic Nursing Art 6
A. General Rules for Cleaning
• Dry dusting of the room is not advisable.
• Dusting should be done by sweeping only
• Use a damp duster for collecting dust
• Dust with clear duster
• Collect dust at one place to avoid flying from place to place
• Dusting should be done without disturbing or removing the patients
from bed
• Dusting should be done from top to bottom i.e. from upward to

downward direction
• While dusting, take care not to spoil the beds or walls or other
fixtures in the room or hospital ward
• While dusting, wounds or dressing should not be opened by other

staff
• There should be a different time for dusting daily
B. Care of Hospital and Health Care Unite Equipments
1. General Instructions for Care of Hospital Equipment

• Use articles only for the purpose for which they are intended
• Keep articles clean and in good condition. Use the proper
cleaning method
• Protect mattresses with rubber sheets

• Use protective pillowcases on pillows.
• Do not boil articles, especially rubber articles and
instruments longer than the correct time
• Do not sterilize rubber goods and glass articles together -

wrap glass in gauze when sterilizing it by boiling
• Protect table tops when using hot utensils or any solution
that may leave stain or destroy the table top
• Report promptly any damaged or missing equipment
2. Care of Equipment in General

• Rinse used equipment in cold water. Remove any sticky
material. Hot water coagulates the protein of organic
material and tends to make it adhere
• Wash well in hot soapy water. Use an abrasive, such as a

stiff-bristled brush, to clean equipment
Basic Nursing Art 7
• Rinse well under running water
• Dry the article
• Clean the gloves, brush and sink
3. Care of Linen and Removal of Stains

• Clean linen should be folded properly and be kept neatly in
the linen cupboard
• Dirty linen should be put in the dirty linen bag (hamper) and
never be placed on the floor
• Torn linen should be mended or sent to the sewing room

• Linen with blood should be soaked in cold water to which a
small amount of hydrogen peroxide is added if available
• Linen stained with urine and feces is first rinsed in cold water
and then washed with soap
• Iodine stained linen- apply ammonia, rinse and then wash

with cold water
• Ink stained linen – first soak in cold water or milk for at least
for 24 hrs then rub a paste of salt and lemon juice on the
stain and allow the article to lie in the sun
• Tea or coffee stains – wash in cold water and then pour

boiling water on the stain
• To remove vitamin B complex stains dissolve in water or
sprit
• Mucus stains – soak in salty water
• Rust _ soak in salt and lemon juice and then bleach in sun
4. Care of Pick Up Forceps and Jars

Pick up forceps: an instrument that allows one to pick up sterile
equipment.
Sterile equipment: material, which is free of all forms of

microorganism.
Pick up forceps should be kept inside the jar in which 2/3 of the jar
should be filled with antiseptic solution
• Wash pick up forceps and jars and sterilize daily

• Fill jar with disinfectant solution daily
• Care should be taken not to contaminate tip of the forceps
• Always hold tip downward
Basic Nursing Art 8
• If tip of forceps is contaminated accidentally, it should be
sterilized before placing it back in the jar to avoid
contamination.
5. Rubber Bags
Example: hot water bottles, ice bags should be drained and dried
They should be inflated with air and closed to prevent the sides
from sticking together
6. Rubber Tubing
• Should be washed with warm, soapy water
• The inside should be flushed and rinsed well
Admission and Discharge
A. Admission
Admission is a process of receiving a new patient to an individual unit
(ward) of the hospital. (Hospitalized individuals have many needs and
concerns that must be identified then prioritized and for which action must
be taken).
Purpose
• To help a new patient to adjust to hospital
• To alleviate the patient's fear and worry about the hospitalization.
Nurse's Responsibilities During Admission of a Patient to Hospital

1. Check for orders of admission
2. Assess the patient's immediate need and take action to meet them.
These needs can be physical (e.g. acute pain) or emotional
distress, (upset)
3. Make introduction and orient the patient

• Greet the patient
• Introduce self to the patient and the family
• Explain what will occur during the admission process
(admission routines) such as admission bath, put on hospital
gowns etc.
• Orient patient to individual unit: Bed, bathroom, call light,

supplies and belonging; and how these items work for
patient use.
Basic Nursing Art 9
• Orient patient to the entire unit: location of nurses office,
lounge etc.
• Explain anything you expect a patient to do in detail. (this

helps the patients participate in their care).
• Introduce other staff and roommates.

4. Perform base line assessment
a. Observation and physical examination such as:
• Vital signs; temperature pulse, respiration and blood
pressure
• Intake and output
• Height and weight (if required)
• General assessment
b. Interview patient and take nursing history to determine what

medication the patient is currently taking, any allergies, and
patient's entering complaints and concern.
5. Take care of the patient's personal property

• Items that are not needed can be sent home with family
members
• Other important items can be kept at bedside or should be

put in safe place by cabling with patient's name.
6. Record keeping or maintaining records

• Record all parts of the admission process
• Other recording include
⇐ Notification to dietary departments
⇐ Starting kardex card and medication records
⇐ If there is specific form to the facility, complete it.
B. Discharging a Patient Indications

for discharge
• Progress in the patient's condition

• No change in the patient's condition (Referral)
• Against medical advice
• Death
Nurse's Responsibility During Discharging a Patient

Basic Nursing Art 10
1. Check for orders that a patient need to be discharged
2. Plan for continuing care of the patient

• Referral as necessary
• Give information for a new person involved in the patient
care.
• Contact family or significant others, if needed.

• Arranging transportation
3. Teaching the patient about
• What to expect
• Medications (Treatments)
• Activity
• Diet
• Need for continued health supervision
4. Do final assessmentof physical and emotionalstatus of the

patient and the ability to continue own care.
5. Check and returnall patients’personalproperty(bath items in

patient unit and those kept in safe area).
6. Help the patient or family to with
deal business office for customary
financial matters and in obtaining supplies.
7. Keep records
o Write discharge note
o Keep special forms for facility
Discharge summaries usually include

:
• Description of client’s
condition at discharge
• Current medication
• Treatment (e.g. Wound, care, O2 therapy)

• Diet
• Activity level
• Restrictions
Reason for referral include the following:

• Any active health problems
• Current medication
• Current treatments that are to be continued
• Eating and sleeping habits
• Self-care abilities
• Support networks
• Life-style patterns
• Religious preferences
Discharging a patient against medical advice (AMA)

1. When the patient want to leave an agency without the permission
of the physician - unauthorized discharge the following activities
are indicated:
2. Ascertain why the person wants to leave the agency

3. Notify the physician of the client’s decision
4. Offer the patient the appropriate form to complete
5. If the client refuses to sign the form, document the fact on the form
and have another health professional witness this
6. Provide the patient with the original of the signed form and place a
copy in the record
7. When the patient leaves the agency, notify the physician, nurse in
charge, and agency administration as appropriate
• Assist the patient to leave as if this were a usual discharge

from the agency (the agency is still responsible while the
patient is on premises)
Charting
Chart: is a written record of history, examinations, tests, diagnosis,

prognosis, therapy and response to therapy
Purpose
• To document diagnosis or treatment of a patient while in
the hospital and after discharge if the patient return for
treatment at a future time.
• To maintaining accurate date on matters demand by courts

• To providing material for research
• To serve as information in the education of health personnel
• To secure needed vital statistics
• To promoting public health
General Rules for Observation and Recording
♦ Spelling
♦ Accuracy
♦ Completeness
♦ Exactness
♦ Legibility
♦ Neatness
♦ Errors
♦ Composition
♦ Sentences
Definition of Signs and Symptoms
Objective information (sign):

The health personnel and the patient
readily observe those signs such
as;
swelling, redness rash, body discharge, vital signs, laboratory results
Subjective information (symptom)

• Felt by the patient only
• Experienced by the patient them selves and made known
to the health personnel only through complaints of patient.
E.g. Nausea, headache, numbness
As part of the admission process a new chart should be
opened and certain forms must be filled
Orders of Assembling Patients Chart a.

Order sheet
b. Progress notes (may differ from hospital to hospital)

c. Nursing notes
d. Vital sign sheet
e. Laboratory
reports
Safety and Comfort Measures and Devices
1. Cotton Rings
: are smallcircles of cotton rolledgauze
withor
bandage with hole in the middle.
Used to relieve pressure from small areas such as the elbows and
hells
2. Air Rings:
• Should be filled with air and covered with pillow

case
Not commonly used
•
• Should be changed frequently
• Used to relieve pressurethe

from
buttocks (to prevent bed
sore)
3. Cradles (Bed Cradle):
• Also called Anderson frame.
• Is a frame, which is made of wire, wood or

iron.
Designed to keep the top bedclothes off the feet, legs, and
•
even abdomen of client in case of injury.
4. Pillow:
• Placed under head, back, between knees or at the foot of
the bed to prevent foot drop and keep the patient.
• Are used to give comfort, support and to position a patient
properly.
5. Sand Bags:
• Are heavy, cylindrical or rectangular sand-filled bags.
• Are used for supporting or immobilizing a limb.
• They should be covered with towel and placed one on either

side of a limb (or part to be
immobilized).
6. Splints:
Are rigid supports that help maintain the wrists in hyperextension as
a means of
Preventing palmar flexion and constructors.
7. Fracture boards:
• Used to make the bed firm and to prevent bed from

sagging.
They are placed under the mattress of patients with
•
fracture.
8. Backrest:
Usedfor elevating
and supporng the headand backof the
patient. ti
• Gatch beds have back rest which can be elevated or lowered

as desired
• Pillows or boards can be

if used
gatch bed is not available
9. Foot rest (board):
• Are rigid, vertical structures.

• Are placed at the foot of the
• bed.Help to maintain the ankles in their normal functional
position in order to prevent foot drop and also prevent the
patient from sliding down.
• Should be padded for support.

• Should be adjusted to the client's height so that the soles
rest firmly against it and the ankles are maintained at 900.
Lifting and Moving a Patient
Body Mechanics: is the effort; coordinated, and safe use of the body to
produce motion and maintain balance during activity
• A person maintains balance as long as the line of gravity

passes through the center of the body and the base support
Line of gravity: an imaginary vertical line drawn through an object’s

center of gravity
• The point at which all of the mass of an object is centered

• Base of support: the foundation on which an object rests
Principles
• Balance is maintained and muscle strain is avoided as long

as the line of gravity passes through the base of support
• The wider the base of support and the lower the center of
gravity, the greater the stability
• Objects that are close to the center of gravity are moved with
the
least effort
Purpose of Proper Body Mechanics
• Promotes body musculoskeletal functioning

• Reduces the energy required to move and maintain balance
• Reduce fatigue and decreases the risk of injury
• Facilitates safe and efficient use of appropriate groups of
muscles
The center of gravity of a well-aligned standing adult is located slightly
anterior to the upper part of the sacrum.
Standing position posture: is unstable because of a narrow base of

support, a high center of gravity and a constantly shifting line of gravity.
Person resting in a chair or bed o The presence of the chair gives
wider base of support o The center of gravity is lower o The line of
gravity is less mobile thus; a person has greater stability and balance in a
sitting or lying position than a standing position.
Moving a Patient
Purpose:
o To increase muscle strength and social mobility o To
prevent some potential problems of immobility o To
stimulate circulation o To increase the patient sense of
independence and self-esteem o To assist a patient who
is unable and move by himself o To prevent fatigue and
injury o To maintain good body alignment
Ensure that the client is appropriately dressed to walk and wears shoes or
slippers with non-skid. Proper attire and footwear prevent chilling and
falling.
• If a client begins to experience the sign and symptoms of

orthostatic hypotension or extreme weakness
⇒ Quickly assist the client into a near by chair or other chair
and help him/her to lower the heed between the knees.
Facilitates blood flow to the brain
⇒ If a chair is not close by assist the client to a horizontal

position on the floor before fainting occurs
Controlling Postural Hypo tension o Sleep with the head of the bed
elevated (8-12 inches). This makes the person’s position change
on rising less severe.
o Avoid sudden changes position. Arise from bed in three

steps:
⇒ Sit on the side of the bed with legs dangling for 1
minute
⇒ Stand with core holding on to the edge or the bed or

another non mobile object for 1 minute
⇒ Sit up in the bed for one minute

Gradual change in position stimulates renin, kidney enzyme that
has a role in regulating BP and which prevents a dramatic drop in
BP o Balance is maintained with minimal effort when the base of
support is enlarged in the direction in which the movement will
occur
o Contracting muscles before moving an object lessens the

energy required to move it
o The synchronized use of as many large muscles groups as

possible during an activity increases overall strength and
prevents muscle fatigue and injury
o The closer the line of gravity to the center of the base of

support, the greater the stability
o The greater the friction against the surface beneath an object

the greater the force required moving the object.
(Pulling creates less friction than pushing) o The heavier the

object, the greater the force needed to move the object
o Moving an object along a level surface required less energy

than moving an object up an inclined surface or lifting it
against gravity
o Continuous muscle exertion can result in muscle stretch and

injury
Study Questions
1. State some of the important general instructions for nursing
procedures.
2. What does patient unit consists of?
3. Mention some of the nursing

sponsibilities
re during admission and
discharge of the patient.
4. List some items commonly used to comfort patient.
5. Define body mechanics.
6. Describe line of gravity in relation to body mechanics.
UNIT THREE
BED MAKING
Learning Objective
Describe different types of bed making

Develop understanding about general instruction of bed making 
Develop a skill to make different types of bed.
Mention purposes of bed making

List necessary equipment for bed making
Arrange bed-making equipment in order of their use.
In most instances beds are made after the client receives certain care
and when beds are unoccupied. Unoccupied bed can be both open and
closed.
Closed bed: is a smooth, comfortable and clean bed, which is prepared

for a new patient
• In closed bed: the top sheet, blanket and bed spread are drawn up
to the top of the bed and under the pillows.
Open bed: is one which is made for an ambulatory patient are made in
the same way but the top covers of an open bed are folded back to make
it easier of a client to get in.
Occupied bed: is a bed prepared for a weak patient who is unable to get
out of bed.
Purpose:
1. To provide comfort and to facilitate movement of the patient
2. To conserve patient’s energy and maintain current health status
Anesthetic bed: is a bed prepared for a patient recovering from
anesthesia
⇒ Purpose: to facilitate easy transfer of the patient from stretcher to
bed
Amputation bed: a regular bed with a bed cradle and sand bags
⇒ Purpose: to leave the amputated part easy for observation
Fracture bed: a bed board under normal bed and cradle

⇒ Purpose: to provide a flat, unyielding surface to support a fracture
part
Cardiac bed: is one prepared for a patient with heart problem

⇒ Purpose: to ease difficulty in breathing
General Instructions
1. Put bed coverings in order of use
2. Wash hands thoroughly after handling a patient's bed linen
Linens and equipment soiled which secretions and excretions harbor
micro-organisms that can be transmitted directly or by hand’s
uniforms
3. Hold soiled linen away from uniform

4. Linen for one client is never (even momentarily) placed on another
client’s bed
5. Soiled linen is placed directly in a portable linen hamper or a pillow

case before it is gathered for disposal
6. Soiled linen is never shaken in the air because shaking can

disseminate secretions and excretions and the microorganisms
they contain
7. When stripping and making a bed, conserve time and energy by
stripping and making up one side as completely as possible before
working on the other side
8. To avoid unnecessary trips to the linen supply area, gather all

needed linen before starting to strip bed
9. Makea verticalor horizontal
toe pleatin the sheetto provide
additional room for the clients feet.
Vertical- make a fold in the sheet 5-10 cm 1 to the foot
Horizontal
– make a fold in the sheet 5-10 cm across the bed near
the foot
10. Whiletuckingbeddingunderthemattressthepalmof thehand
should face down to protect your nails.
Order of Bed Covers

1. Mattress cover
2. Bottom sheet
3. Rubber sheet
4. Cotton (cloth) draw sheet
5. Top sheet
6. Blanket
7. Pillow case
8. Bed spread
Note
• Pillow should not be used for babies

• The mattressshouldbe turnedas oftenas necessaryto prevent
sagging, which will cause discomfort to the patient.
A. Closed Bed
• It is a smooth, comfortable, and clean bed that is prepared for a
new patient
Essential Equipment:
• Two large sheets
• Rubber draw sheet
• Draw sheet
• Blankets
• Pillow cases
• Bed spread
Procedure:
• Wash hands and collect necessary materials
• Place the materials to be used on the chair. Turn mattress and
arrange evenly on the bed
• Place bottom sheet with correct side up, center of sheet on center
of bed and then at the head of the bed
• Tuck sheet under mattress at the head of bed and miter the corner
• Remain on one side of bed until you have completed making the
bed on that side
• Tuck sheet on the sides and foot of bed, mitering the corners
• Tuck sheets smoothly under the mattress, there should be no
wrinkles
• Place rubber draw at the center of the bed and tuck smoothly and
tightly
• Place cotton draw sheet on top of rubber draw sheet and tuck.
The rubber draw sheet should be covered completely
• Place top sheet with wrong side up, center fold of sheet on center
of bed and wide hem at head of bed
• Tuck sheet of foot of bed, mitering the corner

• Place blankets with center of blanket on center of bed, tuck at the
foot of beds and miter the corner
• Fold top sheet over blanket

•
Place bed spread with right side up and tuck it
• Miter the corners at the foot of the bed
• Go to other side of bed and tuck in bottom sheet, draw sheet,
mitering corners and smoothening out all wrinkles, put pillow case
on pillow and place on bed
• See that bed is neat and smooth
• Leave bed in place and furniture in order
• Wash hands
B. Occupied Bed
Purpose:to provide comfort, cleanline
ss and facilitate position of the
patients
Essential equipment:
• Two large sheets
• Draw sheet
• Pillow case
• Pajamas or gown, if necessary
Procedure:
• If a full bath is not given at this time, the patient’s back should be
washed and cared for
• Wash hands and collect equipment
• Explain procedure to the patient
• Carry all equipment to the bed and arrange in the order it is to be

used
• Make sure the windows and doors are closed
• Make the bed flat, if possible
•
• Loosen all bedding from the mattress, beginning at head of the
bed, and place dirty pillow cases on the chair for receiving dirty
linen
Have patient flex knees, or help patient do so. With one hand over the
patient’s shoulder and the shoulder hand over the patient’s knees,
turn the patient towards you
• Never turn a helpless patient away from you, as this may cause
him/her to fall out bed
• When you have made the patient comfortable and secure as near
to the edge of the bed as possible, to go the other side carrying
your equipment with you
• Loosen the bedding on that side

• Fold, the bed spread half way down from the head
• Fold the bedding neatly up over patient
• Roll dirty bottom sheet close to patient
• Put on clean bottom sheet on used top sheet center, fold at center
of bed, rolling the top half close to the patient, tucking top and
bottom ends tightly and mitering the corner
• Put on rubber sheet and draw sheet if needed

• Turn patient towards you on to the clean sheets and make
comfortable on the edge of bed
• Go to the opposite side of bed. Taking basin and wash cloths with
you, give patient back care
• Remove dirty sheet gently and place in dirty pillow case, but not on
the floor
• Remove dirty bottom sheet and unroll clean linen

• Tuck in tightly at ends and miter corners
• Turn patient and make position comfortable
•
• Back rub should be given before the patient is turned on his /her
back
• Place clean sheet over top sheet and ask the patient to hold it if
she/he is conscious
Go to foot of bed and pull the dirty top sheet out

• Replace the blanket and bed spread
• Miter the corners
• Tuck in along sides for low beds
• Leave sides hanging on high beds
•
• Turn the top of the bed spread under the blanket
• Turn top sheet back over the blanket and bed spread
• Change pillowcase, lift

patient’s head to replac
e pillow. Loosen top
bedding over patient’s toes and chest
• Be sure the patient is comfortable
• Clean bedside table
• Remove dirty linen, leaving room in order
• Wash hands
Study Questions
1. How many types of bed making do you know?
2. What is the function of bed the cradle?
3. Which types of bed are usually prepared for newly admitted
patients?
4. What is the difference
between open and closed bed?
5. Define occupied bed.
UNIT FOUR
GENERAL CARE OF THE PATIENT
Learning Objectives
At the end of this unit, the learner able to:

• Describe several aspects of general care to the patient, including
bath oral, hair, perineal area care, giving and receiving bedpan
urinals; and feeding helpless patient.
• Explain the rationale for each patient care procedure.

• Identify and list the materials required to do these procedures.
• Describe the procedure following a logical order
• Demonstrate the ability to perform each of these specific care
procedures of general patient care.
Bath (Bathing and Skin Care)

It is a bath given to a patient in the bed who is unable to care for
himself/herself.
1. Cleansing bath: Is given chiefly for cleansing or hygiene purposes

and includes:
• Complete bed bath: the nurse washes the entire body of a

dependent patient in bed
• Self-help bed bath: clients confined to bed are able to bath

themselves with help from the nurse for washing the back
and perhaps the face
• Partial bath (abbreviated bath): only the parts of the client’s

body that might cause discomfort or odor, if neglected are
washed the face, hands, axilla, perineum and back (the
nurse can assist by washing the back) omitted are the arms,
chest, abdomen.
• Tub bath: preferred to bed baths because it is easier to wash

and rinse in a tub. Also used for therapeutic baths
• Shower: many ambulatory clients are able to use

shower
• The water should feel comfortably warm for the

client
• People vary in their sensitivity to heat generally it should be

43-46 oc (110-115of)
• The water for a bed bath should be changed at
least once
Before bathing a patient, determine

a. The type of bath the client needs
b. What assistance the client needs
c. Other care the client is receiving – to prevent undue fatigue
d. The bed linen required
Note: when bathing a client with infection, the caregiver should wear
gloves in the presence of body fluids or open lesion.
Principles
• Close doors and windows: air current increases loss of heat from
the body by convection
• Provide privacy – hygiene is a personal matter & the patient will be

more comfortable
• The client will be more comfortable after voiding and voiding before
cleansing the perineum is advisable
• Place the bed in the high position: avoids undue strain on the
nurses back
• Assist the client to move near you – facilitates access which avoids
undue reaching and straining
• Make a bath mitt with the washcloth. It retains water and heat
better than a cloth loosely held
• Clean the eye from the inner canthus to the outer using separate
corners of the wash cloth – prev

ents transmitting micro organisms,
prevents secretions from entering the nasolacrmal duct
• Firm strokes from distal to proximalparts of the extremities

increases venous blood return
Purpose:
o To removetransientmoist,body secretionsand excretions,and
dead skin cell
o To stimulate circulation
o To produce a sense of well being
o To promote relaxation, comfort and cleanliness
o To prevent or eliminate unpleasant body odors
o To give an opportunity he
fornurse
t to assess ill clients
o To prevent pressure sores
Two categories of baths given to clients

o Cleansing
o Therapeutic
A. Bed Bath
Equipment
• Trolley
• Bed protecting materials such as rubber sheet and towels

• Bath blanket (or use top linen)
• Two bath towels
• Clean pajamas or gown
• Additional bed linens
• Hamper for soiled cloths
• Basin with warm water (43-460c for adult and 38-400c for children)
• Soap on a soap dish
• Hygienic supplies, such as, lotion, powder or deodorants (if
required)
• Screen
• Disposable gloves
Procedures
1. Prepare the patient unit
• Close windows and doors, use screen to provide privacy.
2. Prepare the patient and the bed

• Place the bed in high position to reduce undue strain on the
nurse's back
• Remove pt's gown and pajamas

• Assist pt to move toward you so it facilitates access to reach
pt without undue straining. Position the pt in supine, semi
Fowler’s or Fowler’s depending on the pt's condition.
3. Make a bath mitt with the washcloth, so it retains water and heat
than a cloth loosely held
4. Washing body parts

• Expose only the parts of the patient's body being washed
avoid unnecessary exposing.
• Wash, rinse and dry each body parts thoroughly using

washing towels and paying particular attention to skin folds.
• Suggested order for washing body parts;

Face, ear, neck
⇒ Arms and hands further away from the nurse
⇒ Chest
⇒ Arms and hands nearest to the nurse
⇒ Buttocks and genital area
⇒ Change the water after it gets dirty
⇒ If possible assist patient to wash own face, hands,
feet and genital area by placing the basin on
bed.
Assist the patient with grooming

• Apply powder lotion or deodorants (of pt uses)

• Help patient to care for hair, mouth and nails.
5. Recomfort the patient

• Change linen if soiled
• Arrange the bed
• Put pt in comfortable position
• Remove the screen
6. Give proper care of materials used for bathing

• Document and report pertinent data
• Observation of the skin condition
• General appearance or reaction of the pt
• Type of bath give
Report any abnormal findings to the nurse in charge
B. Therapeutic Baths
• Are usually ordered by a physician
• Are given for physical effects, such as sooth irritated skin or to treat
an area (perineum)
• Medications may be placed in the water
• Is generally taken in a tub 1/3 or ½ full, about 114 liters (930’gal)

• The client remains in the bath for a desired time, often 20-30
min
• If the clients back, chest and arms are to be treated,
immerse in the solution
• The bath temperature is generally included in the order,

37.7-46oc
(100-115 oF) for adults and 40-50 oc (105 oF) for infants
Bath Solutions
1. Saline: 4 ml (1Tsp) NaCl to 500 ml (1 pt) water
• Has a cooling effect
• Cleans
• Decrease skin irritation
2. Sodium: 4 ml (1Tsp) NCHCO3 to 500 ml (1 pt) water, bicarbonate

or 120-360 ml 120 liters
• Has a cooling effect
• Relieves skin irritation
3. Potassium permanganate4):
(Kmno
available in tablets, which are
crushed, dissolved in a little water, and added to the bath
• Cleans and disinfects
• Treats infected skin areas

Oatmeal (Aveeino) and cornstarch can also be used
Back Care (massage):

includes the area from the back and shoulder to
the lower buttocks
Purpose
• To relieve muscle tension
• To promote physical and mental relaxation
• To improve muscle and skin functioning
• To relieve insomnia
• To relax patient
• To provide a relieve from pain

• To prevent pressure sores (decubitus)
Procedure
1. Prepare the pt and pt's unit
•
Provide privacy by using screen or closing windows and
doors.
• Assist pt to move close to your working side

• Position patient prone (lie on abdomen) if possible. If not
because of the pt's condition, use side lying position with the
pt facing away from you.
• Expose the back of the pt.

• Spread towel close to pt's back to protect foundation of the
bed.
• Wash the back with warm water and soap using wash towel,
rinse and dry it (if it is not given with bath)
2. Massaging the back

• Pour small amount of lotion (oil) on your palm and rub your
palms together to warm the lotion (oil) before massaging.
• Massage the back using appropriate technique Technique

for Back Rub (massage)
• Rub towards the neck line using long, firm, smooth strokes
• Pause at the neckline, using your fingers to massage the
side of the neck.
• With a kneading motion, rub out along the shoulders

continue the kneading motion and move down on each side
of the trunk with both hands until you are again at the sacral
area.
• Then, placing your hands side by side with the palms down,
rub in figure of 8 pattern over the buttock and sacral area.
•
• Next, again using the kneading motion, move up the sides
(about the vertebra) through the intrascapular space towards
the shoulder.
• Ask the pt if there is any area that he/she would especially

like to be rubbed.
Complete the back rub using long, firm strokes up and sown
the back. (shoulder to sacrum and back to shoulder).
3. Recomfort the pt.

• Mop extra oil/lotion from the pt's back using towel.
• Apply powder / alcohol to dry further moisture from the back,
if the skin is moist in its nature
• Dress up the pt's pajama and replace the top cover.

• Reposition the pt.
• Leave the pt comfortably
4. Give proper care of equipments
5. Document the procedure, your observations and pt's reactions

• Report any abnormal observations on the skin of the back
(such as signs of pressure sore) to the nurse and physician
in charge of the pt.
Three Types of Massage Strokes

1. Effleurage: stroking the body
2. Light, circular friction and straight, dup, firm, strokes
3. Petrissape: kneading and making large quick pinches of the skin,
tissue, and muscle
• Clean the back first

•
• Warm the massage lotion or oil before use by pouring over
your hands: cold lotion may startle the client and increase
discomfort
1. Effleurage the entire back: has a relaxing sedative

effect if slow movement and light pressure are used
2. Petrissape first up the vertebral column and them over

the entire back: is stimulating if done quickly with firm
p
Assess: signs of relaxation and /or decreased pain (relaxed
breathing, decreased muscles tension, drowsiness, and
peaceful affect)
⇒ Verbalizations of freedom from pain and tension

⇒ Areas or redness, broken skin, bruises, or other sings of
skin breakdown
Note
• The duration of a massage ranges from 5-20 minutes
• Remember the location of bony prominence to avoid direct
pressure over this areas
• Frequent positioning is preferable to back massage as massaging

the back could possibly lead to subcutaneous tissue degeneration.
Mouth Care
Purpose
• To remove food particles from around and between the teeth
• To remove dental plaque to prevent dental caries
• To increase appetite
• To enhance the client’s feelings of well-being
• To prevent sores and infections of the oral tissue
•
• To prevent bad odor or halitosis
• Should be done in the morning, at night and after each meal
• Wait at least for 10 minutes after patient has eaten
Equipments
• Toothbrush (use the person’s private item. If patient has none use
of cotton tipped applicator and plain water)
• Tooth paste (use the person’s private item. If patient has none of
use cotton tipped applicator and plain water)
• Cup of water
• Emesis basin
• Towel
• Denture bowel (if required)
Procedure
1. Prepare the pt:
• Explain the procedure
• Assist the patient to a sitting position in bed (if the health
condition permits). If not assist the patient to side lying with
the head on pillows.
• Place the towel under the pt's chin.

• If pt confined in bed, place the basin under the pt's chin
2. Brush the teeth

• Moisten the tooth with water and spread small amount of
tooth paste on it
• Brush the teeth following the appropriate technique.

Brushing technique
• Hold the brush against the teeth with the bristles at up

degree angle.
• Use a small vibrating circular motion with the bristle at the

junction of the teeth and gums use the some action on the
front and the back of the teeth.
• Use back and forth motion over the biting surface of the
teeth.
• Brush the tongue last
3. Give pt water to rinse the mouth and let him/her to spit the water
into the basin.
• Assist patient in wiping the mouth

4. Recomfort the pt
• Remove the basin
• Remove the towel
• Assist the patient in wiping the mouth
• Reposition the patient and adjust the bed to leave patient
comfortably
5. Give proper care to the equipments

6. Document assessment of teeth, tongue, gums and oral mucosa.
Report any abnormal findings.
Mouth Wash Solutions

1. Normal solution: a solution of common salt with water in proportion
of 4 gm/500 cc of water
2. Hydrogen peroxide – 5-20 cc (in water)

3. KMNO4 – in crystal form
4cc or KMNO4 solution in a glass of water (1:700) or one small crystal in
a glass of water
4. Soda-bicarbonate solution: 4 gm. of soda in pint of water

5. Thymal solution: ¼ - ½ TSF of thymal in one cup of water (100-150
cc of water)
6. Lemon juice: 2TSF lemon juice in a cup of water - an improvised

method for mouth wash
Flossing
It removes resides particles between the teeth
Technique
1. Wrap one end of the floss around the 3rd finger of each hand
2. To floss the upper teeth. Use the thumb and index finger to stretch
the floss. Move the floss up and down between the teeth from the
tops of the crowns to the gum
3. To floss the lower teeth, use your index fingers to stretch the floss
Note: If the patient has denture remove them before starting and
wash them with brush
Mouth care for unconscious patient
 Position
• Side lying with the head of the bed lowered, the saliva
automatically runs out by gravity rather than being aspirated
by the lungs or if patient's head can not be lowered, turn it to
one side: the fluid will readily run out of the mouth, where it
can be suctioned
• Rinse the patient's mouth by drawing about 10 ml of water or

mouth wash in to the syringe and injecting it gently in to
each side of the mouth
• If injected with force, some of it may flow down the clients

throat and be aspirated into the lung
• All the rinse solution should return; if not suction the fluid to
prevent aspiration
Giving and Receiving Bedpans and Urinals

• Bedpan is a material used to receive urine and feces in
females and feces in male
• Urinal -is used to receive urine

 Are of two types male and female
Types of Bedpan
1. The high back, or regular pan (standard pan)
2. A fracture, the slipper or low back pan Advantage
⇒ Has a thinner rim than as standard bed pan

⇒ Is designed to be easily placed under a person’s buttocks
Disadvantage
⇒ Easier to spill the contents of the fracture pan

⇒ Are useful for people who are
a. Paralyzed or who cannot be turned safely (e.g. Spinal
injury)
b. Confined in a body or long leg cost
c. Immobilized by some types of fracture
d. Very thin or emaciated
3. The pediatric bedpan
• Are small sized
• Usually made of a plastic
Offering and Removing Bed Pan

• If the individual is weak or helpless, two peoples are
needed to place and remove bed pans
• If a person needs the bed pan for a longer time periodically

remove and replace the pan to ease pressure and prevent
tissue damage
• Metal bed pans should be warmed before use by:

o Running warm water inside the rim of the pan or
over the pan
o Covering with cloth

• Semi-Fowler’s position relieves strain on the client’s back and permits a
more normal position for elimination
Improper placement of the bedpan can cause skin abrasion to the

sacral area and spillage o Place a regular bed pan under the
buttocks with the narrow end towards the foot of the bed and the
buttocks resting on the smooth, rounded rim
o Place a slipper (fracture) pan with the flat, low end under the
client’s buttocks
o Covering the bed pan after use reduces offensive odors and
the clients embarrassment
If the client is unable to achieve regular defecation help by attending
to:
1. The provision of privacy

2. Timing – do not ignore the urge to defecate
• A patient should be encouraged to defecate when the urge
to defecate is recognized
• The patient and the nurse can discuss when mass

peristalsis normally occurs and provide time for defecation
(the same time each day)
3. Nutrition and fluids

For a constipated client: increase daily fluid intake, drink hot liquids and
fruit juices etc
For the client with diarrhea – encourage oral intake of foods and fluids
For the client who has flatulence: limit carbonated beverages; avoid
gasforming foods
4. Exercise
• Regular exercise helps clients develop a regular defecation
pattern and normal feces
5. Positioning
• Sitting position is preferred
3
Measures to assist the person to void include:

• Running water in the sink so that the client can hear it
• Warming the bed pan before use
• Pouring water over the perineum slowly
• Having the person assume a comfortable position by

raising the head of the bed (men often prefer to stand)
• Providing sufficient analgesia for pain

• Having the person blow through a straw into a glass of
water – relaxes the urinary sphincter
Perineal Care (Perineal – Genital Care) Perineal

Area:
• Is located between the thighs and extends from the top of

the pelvic bone (anterior) to the anus (posterior)
• Contains sensitive anatomic structures related to sexuality,

elimination and reproduction
Perineal Care (Hygiene)

• Is cleaning of the external genitalia and surrounding area
• Always done in conjunction with general bathing
Patients in special needs of perineal care

• Post partum and surgical patients (surgery of the perineal
area)
• Non surgical patients who unable to care for themselves
• Patients with catheter (particularly indwelling catheter)
Other indications for perineal care are:

1. Genito- urinary inflammation
2. Incontinence of urine and feces
3. Excessive secretions or concentrated urine, causing skin irritation
or excoriation
4. Presence of indwelling urinary (Foley) catheter

5. Post partum care
6. Care before and after some types of perineal surgery
• Bed pan
• Bed protecting materials
• Perineal pad or dressing (if needed)
Procedure
1. Patient preparation
• Give adequate explanation
• Provide privacy
•
Basic NursingFold
Art the
43 top bedding and pajamas (given to expose perineal
area and drape using the top linen.)
• Position pt lying on back with knees flexed and spread apart.
• Place bed protecting materials under the pt's hip
• Place the bedpan under pt's buttock.
2. Cleaning the genital area
• Put on gloves
For Female
• Remove dressing or pad used
• Inspect the perineal areaflammation

for in excoriation, swelling or
any discharge.
Purpose
• To remove normal perineal secretions and odors
• To prevent infection (e.g. when an indwelling catheter is in place)
• To promote the patient's comfort
Equipments
Bath towel
Cotton balls and gauze squares
Pitcher with worm water or/and prescribed solution in container
• Gloves
a. In case of post partum or surgical pt
• Clean by cotton swabs, first the labia majora then the skin folds
between the majora and minora by retracting the majora using
gauze squares, clean from anterior to posterior direction using
separate swab for
each strokes. (This directions lessens the possibility of
urinary tract contamination)
a. In case of non-surgical pts

• Wash or clean the genital area with soapy water using the different
quarters of the washcloth in the same manner.
Female Perineum
• Is made up of the vulva (external genitalia), including the mons
pubis, prepuce, clitoris, urethral and vaginal orifices, and labia
majora and minora
• The skin of the vaginal orifice is normally moist

• The secretion has a slight odor due to the cells and normal vaginal
florae
• The clitoris consists of erectile tissues and many nerves fibers. Is

very sensitive to touch
Care
• Convenient for a woman to be on a bed pan to clean and rinse the
vulva and perineum
• Secretion collects on the inner surface of the labia

• Use on hand to gently retract the labia
• Use a separate section of wash cloth for each wipe in a downward
motion (from urethra to back perineum)
• Then clean the rectal area
Note
• Following genital or rectal surgery, sterile supplies may be required
for cleaning the operative site, E.g. Sterile cotton balls
• The operative site and perineal area may be washed with an

antiseptic solution – apply by squirting them on the perineum from
a squeeze bottle
Male Perineum
• The penis contains pathways for urination and ejaculation through
the urethral orifice (meatus)
• At the end of the penis is the glans covered by a skin flap (fore skin
or prepuce)
• The urethral orifice is located in the center of the penis and opens
at the tip
• The shaft of the penis consists of erectile tissue bound by the
foreskin’s dense fibrous tissue
Care
• Hold the shaft of the penis firmly with one hand and the wash cloth
with the other – to prevent erection – embarrassment
• Use a circular motion, cleaning from the center to the periphery

• Use a separate section of the wash cloth
For Both Sex

Position
• Lying in bed with knee flexed to clean the perineal part and side
lying cleaning the perineal area
• The urethral orifice is the cleanest area and the anal orifice is the
dirtiest area – always stroke from front to back to wash from ‘clean’
to ‘dirty’ parts
Note: Entry of organisms into the urethral orifice can cause UTI
Hair Care
Hair care usually done after the bath and as daily hygienic activities in a
daily base. Hair care includes combing (brushing of hair),
washing/shampooing of hair and pediculosis treatment.
Combing/Brushing of Hair
A patient hair should be combed and brushed daily most patients do this
themselves if the required materials provided and others may need
nurse's help (assistance)
Purpose
• Stimulates the blood circulation to the scalp
• Distribute hair oils evenly and provide a healthy sheem
• Increase the patient's sense of well-being.
Equipments
• Comb (which is large with open and long toothed)
• Hand mirror
• Towel
• Lubricant/oils (if required)
Procedure
1. Prepare the patient
• Position the patient in either sitting or semi-fowler's or flat, if
the pt is weak to seat or unconscious.
• Place the towel over the patient's shoulder, if in sitting

position or over the pillow if pt is in semi-fowler or lying
position.
• Remove any pins and ribbons
2. Comb the hair by dividing the hair

• Hold a section of hair 2-3 inches from the end and comb the
end until it is free from tangles. Move towards the scalp by
combing in the same manner to remove tangles.
• Continue fluffing the hair outward and upward until all the
hairs combed.
• Arrange the hair as neatly and simply as possible according

to the patient's preference of style.
3. Recomfort the pt
• Remove the towel
• Put patient in comfortable position
4. Care of equipment
5. Documentation
Shampooing/Washing the Hair of Patient Confined to Bed
Purpose
• Stimulate blood circulation to the scalp through massaging
• Clean the patients hair so it increa
se a sense of well-being to the pt
Equipments
• Comb and brush
• Shampoo/soap in a dish
• Shampoo basin
• Plastic sheet
• Two wash towels
• Cotton balls
• Water in basin and pitcher
• Receptacle (bucket) to receive the used water
• Lubricants/oil as required
Procedure
• Assist patient to move to the working side of the bed
• Remove any hair accessories (e.g. pins, ribbons etc)
• Brush and comb the hair to remove tangles
2. Arrange the equipments

• Place the plastic sheet under patient's head and shoulder

• Remove the pillows from under the pt's head and place it
under pt's shoulder (to hyper extend the neck)
•
Tuck the towel under the pt's shoulder and neck
• Place (arrange) the shampoo basin under the pt's head with
one end extending to the receptacle for used water.
• If there is no shampoo basin, use the plastic sheet, which is

under pt's shoulder and head, make a funnel type fold and
extend it to the receptacle.

• Place the receptacle on chair/table on the working side of
the bed.
3. Protect the patient's eyes and ears

• Place damp washcloths over the pt's eyes to protect from
soapy water.
• Place cotton balls in the
ent's
patiears to prevent water
collecting in the ear canals.
4. Shampooing/washing the hair

• Wet the hair thoroughly with water
• Apply shampoo (soap) to the scalp.
• Massage all over the scalp symmetrically using your
fingertips
• Rinse the hair with plan water to remove the shampoo/soap
• Remove damp washcloth from pt eyes and cotton balls from
ears.
5. Dry the patient's hair

• Squeeze the hair with your hands to remove as much water
as possible
• Rub pt's hair with towel
• Use hair drier (if available)
6. Ensure pt's comfort

•
• Remove plastic sheet shampoo basin
• Assist pt for comfortable position
Assist pt in grooming
8. Documentation and reporting
Pediculosis Treatment
Purpose
• To prevent transmission of some arthropod born diseases
• To make patient comfortable Definition
Pediculosis: infestation with lice
Lice:
• Are small, grayish white, parasitic insects that infest mammals
• Are of three common kinds:
¾ Pediculose capitis: is found on the scalp and tends to stay
hidden in the hairs
¾ Pediculose pubis: stay in pubic hair

¾ Pediculose corporis: tends to cling to clothing, suck blood
from the person and lay their eggs the clothing suspect their
presence in the clothing if:
a. The person habitually scratches

b. There are scratches on the skin, and
c. There are hemorrhagic spots in the skin where the lice
have sucked blood
Head and body lice lay their eggs on the hairs then eggs look like oval
particles, similar to dandruff, clinging to the hair.
Treatment of Pediculosis
•
Pediculosis Capitus
1. DDT (Dichloro Diphenyl Trichloro Ethane) one part to nine parts of
talcum powder
Can destroy the lice in about 2 hrs
• The effect lasts for 6 days if not washed
• Does not destroy nit or eggs
• Also available in liquid forms
2. Kerosene Oil mixed with equal parts of sweet oil
• Destroys both adult lice and eggs of nits
• From aesthetic point of view, kerosene causes foul smell
and create discomfort to patient and the attendant
Guidelines for Applying Pediculicides Hair:
• Apply pediculicide shampoo to dry hair until hair is

thoroughly saturated and work shampoo in to a lather
• Allow product to remain on hair for stated period (varies with

products)
• Pin hair and allow to dry

• Use a fine toothed comb to remove death lice and nits
(comb should not be shared by other family members)
• Repeat it in 8-10 days to remove any hatched nits
• Apply pediculious lotion (or cream) to affected areas
• Bath after 12 hrs and put on clean clothes
3. Oil of Sassafras
• Is a kind of scented bark oil
• Only destroy lice not nits
• For complete elimination, the oil should be massaged again
after 10 days when the nits hatch
•
• Is used daily for a week with equal parts of Luke warm H 2O
then it should be repeated after a week
4. Gcmmaxine (Gamma Bengenhexa Chloride)

Emphasize the need for treatment of sexual partner
• After complete bathing wash linen available as a cream,
lotion, and a shampoo
• 1.5% solution of Gammaxine effective to kill the adult lice in

one application
• Does not kill nits

• Should be repeated to kill the newly hatched nits, for
complete elimination
• The lotion is applied over scalp after a clean soapy wash of

hair
• After 12-24 hrs the scalp is washed with soap to remove the
lotion
• Avoid contact with lice
• Can also be used for pubic and body lice
Feeding a Helpless Patient

During illness, trauma or wound healing, the body needs more nutrients
than usual. However, many peoples, because of weakness, immobility
and/or one or both upper extremities are unable to feed themselves all or
parts of the meal. Therefore, the nurse must be knowledgeable, sensitive
and skillful in carrying out feeding procedures.
Purpose
• To be sure the pt receives adequate nutrition
• To promote the pt well-beings
Procedure
1. Prepare pt units
• Remove all unsightly equipments; remove solid linens and
arranging bedside tables.
Control unpleasant odors in the room by refreshing the room.
Oder free environment makes eating more pleasant and aids
digestion.
2. Prepare the patients

• Offers bedpan and urinals. To comfort pt and avoid
interruption by elimination needs.
• Assist pt to wash hands, face and oral care

• Position patient comfortably
⇒ Mid or high Fowler's position
• Protect the bed using suitable protective cover
3. Prepare the food tray
• Identify the types of diet ordered.
• Assess any special conditions in which the pt delayed or
omitted (e.g. Lab, radiologic examination or surgery)
• Assess any cultural or religious limitations, specific likes or

dislikes.
• Obtain any special utensils that you planned to use
4. Feed the patient

• Place the food tray in such a way that the patient can see
the food.
• Position yourself at pt's eye level, if at all possible

⇒ Digestion is better when pt is not emotionally upset.
•
• Never hurry a pt's eating. This can make pt uncomfortable
and fearful of taking up your time.
• Allow pt to determine when enough has been eaten, as way

of providing choices.
5. Comfort patient
• Assist hand washing and oral care
Offer bedpan and commodes, of indicated
• Comfort patient, provide quite environment so that the pt
may relax after meal, which also promote good digestion.
8. Document feeding and any assessment
Morning, Afternoon, and Evening Care
• Morning,
afternoon,
andeveningcareare usedto describethe
type of hygienic care given at different times of the day
Early Morning Care
• Is provided to clients as they awaken in the morning
• In a hospital it is provided by nurses on the night shift
• Helps clients ready themselves for breakfast or for early diagnostic

tests
Consists of:
• Providing a urinal or bed pan if client is confined to bed
• Washing the face and hands and
• Giving oral care
Morning Care
• Is provided after clients have breakfast
Includes:
• The provision of a urinal or bed pan
• A bath or shower
• Perineal care
• Back massage and
• Oral, nail and hair care
• Making clients bed
Afternoon Care
• When clients return from physiotherapy or diagnostic tests
• Includes:
 Providing bed pan or urinal
 Washing the hands and face

 Assisting with oral care refresh clients
Evening (Hour of Sleep (HS)) Care
• Is provided to clients before they retire for the night
• Involves:
 Providing for elimination needs
 Washing face and hands
 Giving oral care
 Back massage care (PRN)
As needed (PRN) Care
• Is provided as required by client

E.g. a clientwho is diaphoretic
(sweatingprofusely)may need
bathing and changes of clothes and linens frequently.
Study Questions
1. Explain the purpose of bed bath, mouth care, and perineal care.
1. Describe therapeutic bath.
2. State the three types of
ssage
ma strokes used in back care.
3. Which position is appropriate to give perineal care in both sexes?
UNIT FIVE
OBSERVATION AND LABORATORY DIAGNOSIS
Learning Objectives
At the end of the unit the learner will be able to:
• Assess sign and symptoms of the patients.
• Assist the patient in laboratory diagnosis.
• Collect specimen with accuracy as indicated.
• Take vital signs and interpret the finding.
• Record, maintain and communicate the finding.
• Give appropriate care based on the finding.
I. Observations and Recording of Signs and Symptoms of the

Patient
1. Objective Symptoms (signs):

Are symptoms, which could be seen by the health personnel?
E.g. swelling, redness, rash, body discharges (defecation,
diaphoresis, emesis,)
2. Subjective Symptoms
Are symptoms, which are felt by the patient?
E.g. decrease of appetite, dizziness, deafness, burning sensation,
nausea, etc
3. Charting
Definition: it is a written record of history, examination, tests, diagnosis,
and prognosis response to therapy
Purpose of Patients Chart

a. For diagnosis or treatment of a patient while in the hospital
(find after discharge) if patient returns for treatment in the
future time
b. For maintaining accurate data on matters demanded by
courts
c. For providing material for research
d. For servingan information
in the educationof health
personnel (medical students, interns , nurses, dietitians, etc)
e. For securing needed vital statistics
f. For promoting public health
General Rules for Charting
• Spelling
Make certain you spell correctly
• Accuracy
Records must be correct in all ways, be honest
• Completeness
No omission, avoid unneces
sary words or statement
• Exactness
Do not use a word you are not sure of
• Objective information
Record what you see avoid saying (condition better)
• Legibility
Print/write plainly and distinctively as possible
• Neatness
No wrinkles, proper speaking of items
Place all abbreviation, and at end of statement
• Composition / arrangement
Chart carefully consult if in doubt avoid using of chemical

formulas
• Sentences
Need not be complete but must be clear, avoid repetition
• Time of charting
Specific time and date
• Color of ink
Black or blue (red for transfusion, days of surgery)
It should be recorded on the graphic sheet
All ordersshouldbe writtenand signed. Verbalor telephone
orders should be taken only in emergency verbal orders should be
written in the order sheet and signed on the next visit.
Orders of Assembling Patients Chart

a. Order sheet
b. Doctor’s progress notes
c. Nurses notes
d. Graphic
e. Laboratory reports
• Patientsor relativesandfriendsof patientsare not

allowed to read the chart
4. Intake and out put
a. Intake:all fluidsthatis takenin to thebodythrough
the
mouth, n/g tube or
b. parentrally
Output:all fluidthatis excretedor putoutof thebody
through the mouth. N/G tube, urethra, drainage tube or
other route
Purpose:
• To replace fluid losses
• To provide maintenance requirements

• To check for retention of body fluid
Fluid balance sheet
♦ 24 hrs the intake out put should be compared and the balance
is recorded
¾ Positive balance if intake >output

¾ Negative balance if out put >intake
II. Vital Signs (Cardinal Signs)

• Are signs that reflect changes in the functions of the body
• Includes: T, PR, RR, and BP
Times to Assess Vital Signs

1. On admission – to obtain baseline date
2. When a client has a change in health status or reports symptoms
such as chest pain or fainting
3. According to a nursing or medical order

4. Before and after the administration of certain medications that
could effect RR or BP
(Respiratory and CVs)

5. Before and after surgery or an invasive diagnostic procedures
6. Before and after any nursing intervention that could affect the v/s.
E.g. Ambulation
I Temperature
Factors Affecting Body Temperature

1. Age
• Children’s temperature continue to be more labile than those
of adults until puberty
• Elderly people, particularly those > 75 are at risk of

hypothermia
• Normal body temperature of the newborn if taken orally is 37

0 C.
2. Diurnal variations (circadian rhythms)

• Body temperature varies through out the day
• The point of highest body temperature is usually reached
between 8:00 p.m. and midnight and lowest point is reached
during sleep between 4:00 and 6:00 a.m.
3. Exercise
• Hard or strenuous exercise can increase body temperature
to as high as 38.3 – 40 c – measured rectally
4. Hormones
• In women progesterone secretion at the time of ovulation
raises body temperature by about 0.3 – 0.6 oc above basal
temperature.
5. Stress
• Stimulation of skin can increases the production of
epinephrine and nor epinephrine – which increases
metabolic activity and heat production.
6. Environment
• Extremes in temperature can affect a person’s temperature
regulatory systems.
Alterations in Body Temperature

Normal body temperature is 37 0 C or 98.6 0F (Average) the range is 3638
0
c (96.8 – 100 0F)
Pyrexia: a body temperature above the normal ranges 38 0c – 410 c

(100.4 – 105.8 F)
Hyper pyrexia: a very high fever, such as 41 0 C > 42 0c leads to death.

A client who has fever is referred to as febrile; the one who has not is a
febrile.
Hypothermia: – body temperature between 34 0c – 35 0c, < 34 0c is

death
Common Types of Fevers

1. Intermittent fever: the body temperature alternates at regular
intervals between periods of fever and periods of normal or
subnormal temperature.
2. Remittent fever: a wide range of temperature fluctuation (more than

2 0c) occurs over the 24 hr period, all of which are above normal
3. Relapsing fever: short febrile periods of a few days are interspersed

with periods of 1 or 2 days of normal temperature.
4. Constant fever: the body temperature fluctuates minimally but

always remains above normal
Measuring Body Temperature
There are Two Kinds of Body Temperature

1. Core Temperature
• Is the Temperature of the deep tissues of the body, such as
the cranium, thorax, abdominal cavity, and pelvic cavity
• Remains relatively constant

• Is the Temperature that we measure with thermometer
2. Surface Temperature:
• The temperature of the skin, the subcutaneous tissue and fat
Sites of Measure Temperature

Most common are:
• Oral
• Rectal
• Axillary
• Tympanic membrane
Thermometer: is an instrument used to measure body temperature

Types
1. Oral thermometer
• Has long slender tips
2. Rectal thermometer
• Short, rounded tips
3. Axillary
• Long and slender tip
1. Rectal Temperature:
Readings are considered to be more accurate, most reliable
Contraindication
• Rectal or perineal surgery;
• Fecal impaction – the depth of the thermometer insertion
may be insufficient;
• Rectal infection;
• Neonates –can cause rectal perforation and ulceration;
• Is > 0.650 c (1 0F) higher than the oral temperature;
• Position the person laterally;
• Apply lubricant 2.5 cm above the bulb;
• Insert the thermometer 1.5 – 4 cm into the anus. For an

infant 2.5cm, for a child 3.7 cm – for an adults 4 cm
• Measured for 2-3 minutes

• A rectal thermometer record does not respond to changes in
arterial temperature as quickly as an oral thermometer
2. Oral
• Most accessible and convenient
• The thermometer tip is placed beside the frenulum below the
tongue
• Is 0.65 (1 F) more than the axillary

• The recommended time is 2-3 minutes
• If a client has been taking cold or hot food or fluids or
smoking wait 30 minutes
Contraindication
• Child below 7 yrs
• If the patient is delirious, mentally ill
• Unconscious
• Uncooperative or in severe pain
• Surgery of the mouth
• Nasal obstruction
• If patient has nasal or gastric tubs in place
3. Axillary
• Safest and most noninvasive
• The bulb of thermometer is placed in the clients axillary
hollow
• Leave it in place for 5-10 minutes
II. Pulse
It is a wave of blood created by contraction of the left ventricle of the

heart. i.e. the pulse reflects the heart beat or is the same as the rate of
ventricular contractions of the heart – in a healthy person.
In some types of cardiovascular diseases heartbeat and pulse rate

differs. E.G. Client's heart produces very weak or small pulses that are
not detectable in a peripheral pulse far from the heart
Peripheral Pulse: is a pulse located in the periphery of the body e.g. in

the foot, and or neck
Apical Pulse (central pulse): it is located at the apex of the heart The
PR is expressed in beats/ minute (BPM)
Pulse Deficit
Factors Affecting Pulse Rates

1. Age: as age increase the PR gradually increases. New born to 1
month – 130 BPM 80-180 (range). Adult 80 BPM(beat per minute)
– 60 – 100 BPM(beat per minute)
2. Sex: after puberty the average males PR is slightly lower than

female
3. Exercise: PR increase with exercise

4. Fever: increases PR in response to the lowered B/P that results
from peripheral vasodilatation – increased metabolic rate
5. Medications: digitalis preparation decreases PR, Epinephrine –

increases PR
6. Heat: increase PR as a compensatory mechanism

7. Stress: increases the sympathetic nerve stimulation – increases
the rate and force of heart beat
8. Position changes: when a patient assumes a sitting or standing

position blood usually pools in dependent vessels of the venous
system. Pooling results in a transient decrease in the venous

blood return to heart and subsequent decrease in BP increases
heart rate.
Pulse Sites
1. Temporal: is superior (above) and lateral to (away from the
midline of) the eye
2. Carotid: at the side of the neck below tube of the ear (where the
carotid artery runs between the trachea and the
sternoclidiomastoid muscle)
3. Apical: at the apex of the heart: routinely used for infant and
children < 3 yrs
4. In adults – Left midclavicular line under the 4 th, 5th, 6th intercostals
space
5. Children < 4 yrs lt. Of the Lt. mid clavicular line

6. Brachial: at the inner aspect of the biceps muscle of the arm or
medially in the antecubital space (elbow crease)
7. Radial: on the thumb side of the inner aspect of the wrist – readily
available and routinely used
8. Femoral: along the inguinal ligament. Used or infants and

children
9. Popiliteal: behind the knee. By flexing the knee slightly

10. Posterior Tibial: on the medial surface of the ankle
11. Pedal (Dorslais Pedis): palpated by feeling the dorsum (upper
surface) of the foot on an imaginary line drawn from the middle of
the ankle to the surface between the big and 2 nd toes
Method
Pulse: is commonly assessed by palpation (feeling) or auscultation
(hearing)
The middle 3 fingertips are used with moderate pressure for palpation of
all pulses except apical; the most distal parts are more sensitive,
Assess the Pulse for

• Rate
• Rhythm
• Volume
• Elasticity of the arterial wall
Pulse Rate
• Normal 60-100 b/min (80/min)
• Tachycardia – excessively fast heart rate (>100/min)
• Bradycardia < 60/min
Pulse Rhythm
• The pattern and interval between the beats, random,
irregular beats – dysrythymia
Pulse Volume: the force of blood with each beat

• A normal pulse can be felt with moderate pressure of the
fingers and can be obliterated with greater pressure.
• Full or bounding pulse forceful or full blood volume

obliterated with
difficulty
• Weak, feeble or thready readily obliterated with pressure
from the finger tips
Elasticity of arterial wall

• A healthy, normal artery feels, straight, smooth, soft and

pliable, easily bent after breaking
• Reflects the status of the clients vascular system

If the pulse is regular, measure (count) for 30 seconds and multiply
by 2
If it is irregular count for 1 full minute
III Respiration
Respiration is the act of breathing (includes intake of o2 and co2)

Ventilation is another word, which refer to the movement of air in and out
of the lungs.
Hyperventilation: very deep, rapid respiration

Hypoventilation: very shallow respiration
Two Types of Breathing

1. Costal (thoracic)
• Involves the external muscles and other accessory muscles
(sternoclodio mastoid)
• Observed by the movement of the chest up ward and down

ward
2. Diaphragmatic (abdominal)
• Involves the contraction and relaxation of the diaphragm, observed
by the movement of abdomen.
Assessment
• The client should be at rest
• Assessed by watching the movement of the chest or abdomen.
• Rate, rhythm, depth and special characteristics of respiration are
assessed
A. Rate: is described in rate per minute (PRM)

Healthy adult RR = 15- 20/ min. Is measured for full minute, if regular for
30 minutes.
1. Eupnoea- normal breathing rate and depth

2. Bradypnea- slow respiration
3. Tachypnea - fast breathing
4. Apnea - temporary cessation of breathing
B. Rhythm: is the regularity of expiration and inspiration

Normal breathing is automatic & effortless.
C. Depth: described as normal, deep or shallow.

Deep: a large volume of air inhaled & exhaled, inflates
most of the lungs.
Shallow: exchange of a small volume of air minimal use of

lung tissue.
IV Blood Pressure
Arterial BP: is a measure of a pressure exerted by the blood as it flows

through the arteries
There are two types of blood pressure.

1. Systolic pressure: is the pressure of the blood as a result of
contraction of the ventricle
(is the pressure of the blood at the height of the blood wave);
2. Diastolic blood pressure: is the pressure when the ventricles are

at rest.
3. Pulse pressure: is the difference between the systolic and
diastolic pressure
Blood pressure is measured in mm Hg and recorded as fraction. A

number of conditions are reflected by changes in blood pressure.
Conditions Affecting Blood Pressure

Fever Increase
Stress "
Arteriosclerosis "
Obesity "
Hemorrhage Decrease
Low hematocrit "
External heat "
Exposure to cold Increase
Sites for Measuring Blood Pressure

1. Upper arm using brachial artery (commonest)
2. Thigh around popliteal artery
3. Fore -arm using radial artery
4. Leg using posterior tibial or dorsal pedis
Methods of Measuring Blood Pressure

Blood pressure can be assessed directly or indirectly
1. Direct (invasive monitoring) measurement involves the insertion of
catheter in to the brachial, radial, or femoral artery. The physician inserts
the catheter and the nurse monitors the pressure reading. With use of
correct placement, it is highly accurate.
2. Indirect (non invasive methods)

A. The auscultatory
B. The palpatory, and
C. The flush methods
The auscultatory method is the commonest method used in health

activities.
When taking blood pressure using stethoscope, the nurse identifies five
phases in series of sounds called Korotkoff's sound.
Phase 1: The pressure level at which the 1st joint clear tapping sound is
heard, these sounds gradually become

re intense.
mo To ensure that they
are not extraneous sounds, the nurse. should identify at least two
consecutive tapping sounds.
Phase 2:The period during deflation when the sound has a swishing
quality
Phase 3:The period during which the sounds are crisper and more
intense
Phase 4:The time when the sounds become muffled and have a soft
blowing quality
Phase 5:The pressure level when the sounds disappear
Procedure
Assessing Blood pressure (ARM)
Purpose
o To obtain base line measure of arterial blood pressure for
subsequent evaluation
o To determine the
ents
cli homodynamic status
o To identify and monitor changes in blood pressure resulting
from a disease process and medical therapy.
EQUEPMENT o
Stethoscope
o Blood pressure cuff of the appropriate size o

Sphygmomanometer
Intervention
1. Prepare and position the patient appropriately

• Make sure that the client has not smoked or ingested
caffeine, with in 30 minutes prior to measurement.
• Position the patient in sitting position, unless otherwise

specified. The arm should be slightly flexed with the palm of
the hand facing up and the fore arm supported at heart
level
• Expose the upper arm
2. Wrap the deflated cuff evenly around the upper arm.

• Apply the center of the bladder directly over the medial
aspect of the arm. The bladder inside the cuff must be
directly over the artery to be compressed if the reading to
be accurate.
• For adult, place the lower border of the cuff approximately 2

cm above antecubital space.
3. For initial examination, perform preliminary palipatory

determination of systolic pressure
• Palpate the brachial artery with the finger tips

• Close the valve on the pump by turning the knob clockwise.
• Pump up the cuff until you no longer feel the brachial pulse
• Note the pressure on sphygmomanometer at which the
pulse is no longer felt
• Release the pressure completely in the cuff, and wait 1 to 2

minutes before making further measurement
4. Position the stethoscope appropriately

• Insert the ear attachments of the stethoscope in your ears
so that they tilt slightly fore ward.
• Place the diaphragm of the stethoscope over the brachial
pulse; hold the diaphragm with the thumb and index finger.
5. Auscultate the client's blood pressure

• Pump up the cuff until the sphygmomanometer registers
about 30 mm Hg above the point where the brachial pulse
disappeared.
• Release the valve on the cuff carefully so that the pressure

decreases at the rate 2-3 mmHg per second.
• As the pressure falls, identify the manometer reading at

each of the five phases
• Deflate the cuff rapidly and completely

• Repeat the above step once or twice as necessary to
confirm the accuracy of the reading.
6. Remove the cuff from the client’s arm
7. For initial determination, repeat the procedure on the client's other

arm, there should be a difference of no more than 5 to 10 mmHg
between the arms. The arm found to have the higher pressure,
should be used for subsequent examinations
8. Document and report pertinent assessment data, report any

significant change in client's blood pressure to the nurse in charge.
Also report these finding:

A. Systolic blood pressure (of adult) above 140 mmHg.
B. Diastolic blood pressure (of an adult) above 90 mmHg
C. Systolic blood pressure of (an adult) below 100mmHg
III. Specimen Collection
Specimen collection refers to collecting various specimens (samples),

such as, stool, urine, blood and other body fluids or tissues, from the
patient for diagnostic or therapeutic purposes.
Various types of specimen collected from the patient in the clinical
settings, either in out patient departments (OPD) or in-patient units, for
diagnostic and therapeutic purposes. These includes, stool, urine, blood
and other body fluid or tissue specimens.
General Considerations for Specimen Collection

When collecting specimen, near gloves to protect self from contact with
body fluids.
1. Get request for specimen collection and identify the types of

specimen being collected and the patient from which the specimen
collected.
2. Get the appropriate specimen container and it should be clearly

labeled have tight cover to seal the content and placed in the plastic
bag or racks, so that it protects the laboratory technician from
contamination while handling it.
• The patient's identification such as, name, age, card

number, the ward and bed number (if in-patient).
• The types of specimen and method used (if needed).

• The time and date of the specimen collected.
3. Assemble and organize all the necessary materials for the specimen
collection.
4. Give adequate explanation to the patient about the purpose, type of

specimen being collected and the method used.
5. When collecting specimen wear gloves to protect self from contact

with the specimen (body fluids in particular)
6. Put the collected specimen into its container without contaminating

outer parts of the container and its cover.
7. All the specimens should be sent promptly to the laboratory, so that

the temperature and time changes do not alter the content.
A. Collecting Stool Specimen
Purpose
• For laboratory diagnosis, such as microscopic examination, culture and
sensitivity tests.
Equipments required
• Clean bedpan or commode
• Wooden spatula or applicator
• Specimen container
• Tissue paper
• Laboratory requests
• Disposable glove, for patients confined in bed
• Screen
• Hand washing sets
Procedure
i) For ambulatory patient
Give adequate instruction to the patient to
• Defecate in clean bedpan or commode (toilet)
• Avoid contaminating
the specimenby urine,menstrual
period or used tissue papers, because these may affect the
laboratory analysis.
• Void before collecting the specimen
• Transferthe sample(specimen)to the containerusing

spatula or applicator
ii) For patients confined in bed

1. Prepare the patient's unit
• Provide privacy by drawing screen, closing windows and doors
(To provide privacy)

• Put on gloves
• Position the patient
• Place bed protecting materials under the patient's hips
• Assist the patient and place the bed pan under the patient's
buttocks(followthe steps under"Givingand removing

bedpan")
• Give patient privacy by leaving alone, but not far
• Instructthe patient
abouthow to notifyyouwhen finished
defecation.
• Remove the bedpan and keep on safe place by covering it
• Recomfort the patient
3. Obtain stool sample
• Take the used bedpan to utility room/toilet container using

spatula or applicator without contaminating the outside of the
container.
• The amount of stool specimen to be taken depends on the

purpose, but usually takes.
o 3.5cm sample from formed stool
o 15.30ml sample from liquid stool
• Visible mucus, pus or blood should be included into sample

stool specimen taken.
4. Care of equipments and the specimen collected.

• Handle and label the specimen correctly
• Send the specimen to the laboratory immediately, unless
there is an order for its handling. Because fresh specimen
provides the most accurate results.
• Dispose the bedpan's content and give proper care of all
equipments used.
5. Documentation and report
B. Collecting Urine Specimen

Types of urine specimen collection

1. Clean voided urine specimen
(Also called clean catch or midstream urine specimen)
2. Sterile urine specimen
3. Timed urine specimen
• It is two types
Short period
→ 1-2 hours
Long period
→ 24 hours
Purpose
• For routine laboratory analysis
• To cheek the presence of cells or microorganisms
• For culture and sensitivity tests
Equipments Required
• Laboratory requisition form (Completely filled)
• Water and soap or cotton balls and antiseptic solutions (swabs).
For patients confined

• Urine receptacles (i.e. bedpan or urinals)
• Screen (if required)
Procedure
i) For ambulatory patients
Give adequate instruction to the patient about
• The purpose and method of
taking specimen
• Assist the patient to move to the

toilet ii) For patient confined in bed
1. Prepare the patient unit providing privacy

• Put on gloves
• Place bed protecting materials under patient's hips
• Assist the patient to position in bed and in positioning the
receptacles
• Assist the patient or clean the vulva or penis thoroughly

using soap and water or antiseptic swabs (Follow the steps
of giving and receiving bed pan/urinal and cleaning the
genitalia)
3. Obtain urine specimen

• Ask patient to void
• Let the initial part of the voiding passed into the receptacle
(bed pan or urinal) then pass the next part (the midstream)
into the specimen container.
• Hold the vulva or penis apart from the specimen container

while the patient voids to decrease urine contamination.
• Don't allow the container to touch body parts

• Collect about 30-60 ml midstream urine
• Handle the outside parts of the container and put on the
cover tightly on specimen container
• Clean the outside parts of the container with cotton if

spillage occurs
• Remove the glove
5. Care of the specimen and the equipment

• Handle and label the container correctly

• Send the urine specimen to the laboratory immediately
together with the completed laboratory requested forms
• Empty the receptacles content properly

• Give appropriate care for the used equipments
6. Document pertinent data's and report abnormal observation,

such as
• Specimen collected, amount, time and date.

• Pertinent observation of the urine
• Patients experience during voiding
Collecting a Sterile Urine Specimen

Sterile urine specimen collected using a catheter in aseptic techniques
(The whole discussion for this procedure presented on the catheterization
part)
Collecting a Timed Urine Specimen

Purpose
• For some tests of renal functions and urine compositions,
such as:- measuring the level of adrenocortico steroid or
hormones, creatinine clearance or protein quantitation tests.
Equipments Required
• Urine specimen collecting materials (usually obtained from
the laboratory and kept in the patient's bathroom.)
• Format for recording the time, date started and end, and the
amount of urine collected on each patient's voiding during
the specified period for collection.
Procedure
• Adequate explanation to the patient about the purpose of the
test, when it begins and what to do with the urine
• Place alert signs about the specimen collection at the

patient's bedside or bathroom.
• Label the specimen container to include date and time of

each voiding as well as patient's identification data
• Containers may be numbered sequentially (e.g. 1 st, 2nd, 3rd

etc)
2. Collecting the urine

• Usually it is begin in the morning
• Before you begin the timing, the patient should void and do
not use this urine (It is the urine that has been in the bladder
some time)
• Then all urine voided during the specified time (e.g. the next
24 hours) is collected in the container
• At the end of the time (e.g. 24 hours period) the patient

should void the last specimen, which is added to the rest.
• Ensure that urine is free of feces
C. Collecting sputum specimen

Sputum is the mucus secretion from the lungs, bronchi and trachea, but it
is different prom saliva. The best time for sputum specimen collection is
in the morning up on the patient's awaking (that have been accumulated
during the night). If the patient fails to cough out, the nurse can obtain
sputum specimen by aspirating pharyngeal secretion using suction.
Purpose
Sputum specimen usually collected for
• Culture and sensitivity test (i.e. to identify the microorganisms
and sensitive drugs for it)
• Cytological examination
• Acid fast bacillus (AFB) tests
• To assess the effectiveness of the therapy
Equipments Required
• Laboratory requisition form
• Mouth care (wash) tray
Procedure
• Before collecting sputum specimen, teach pt about the difference

betweensputumand saliva,howto coughdeeplyto raise
sputum.
• Position the patient, usually sitting up position and splinting may

help. Also postural drainage can be used.
• Give oral care, to avoid sputum contaminationwith

microorganisms of the mouth.
d using
Avoitooth past because it
alter the result.
2. Obtain sputum specimen

• Put on gloves, to avoid contact with sputum particularly it
hemoptysis (blood in sputum) present.
• Ask pt to cough deeply to raise up sputum
• Take usually about 15-30 ml sputum
• Ask pt to spit out the sputum into the specimen container
• Make sure it doesn't contaminate the outer part of the
container. If contaminated clean (wash) with disinfectant
• Cover the cape tightly on the container

• Give oral care following sputum collection (To remove any
unpleasant taste)
4. Care of the specimen and the equipments used

• Label the specimen container
• Arrange or send the specimen promptly and immediately to
laboratory.
• Give proper care of equipments used
5. Document the amount, color, consistency of sputum, (thick, watery,

tenacious) and presence of blood in the sputum.
D. Collecting Blood Specimen

The hospital laboratory technicians obtain most routine blood specimens.
Venous blood is drown for most tests, but arterial blood is drawn for
blood gas measurements. However, in some setting nurses draw venous
blood.
Purpose
Specimen of venous blood are taken for complete blood count, which
includes
• Hemoglobin and hemotocrit measurements

• Erythrocytes (RBC) count
• Leukocytes (WBC) count
• Differential RBC or WBC counts
Equipment
• Sterile gloves
• Tourniquet
• Antiseptic swabs
• Dry cotton (gauze)
• Needle and syringe
• Specimencontainerwiththe requireddilutingor preservative

agents
• Identification/ labeling
• Laboratory requisition forms
Procedure
• Instruct the pt what to

ct expe
and for fasting (if required)
• Position the pt comfortably
2. Select and prepare the vein sites to be punctured
• Put on gloves
• Select the vein to be punctured. Usually the large superficial

veins used such as, brachial and median cubital veins.
• Place the veins in dependent positions
• Apply tourniquet firmly 15-20

about
cmthe selected sites. It
must be tight enough to obstruct vein blood flow, but not to
occlude arterial blood flow.
• If the vein is not sufficiently

to dilate massage (stroke) the
vein from the distal towards the site or encourage the pt to
clench and unclench repeatedly.
• Clean the punctured site using antiseptic swabs
3. Obtain specimen of the venous to blood

• Adjust the syringe and needles
• Puncture the vein sites
• Release the tourniquet when you are sure in the vein
• Withdraw the required amount of venous blood specimen •

Withdraw the needle and hold the sites with dry cotton (to
apply pressure)
• Put the blood into the specimen container
• Made sure not to contaminateerout

part of the container and
not to distract the blood cells while putting it into the
container
5. Care of the specimen and the equipment
• Label the container
• Shake gently (if indicated to mix)
• Send immediately to laborator

y, accompanying the request
• Give care of used equipments
6. Documentation and reporting
Study Questions
1. Differentiate between signs and symptoms.
2. Explain vital sings and list what it includes.
3. Identify important times to assess vital signs.
4. Mention some of the factor
s affecting body temperature.
5. What does pulse deficit mean?
6. Define arterial blood pressure.
7. Explain the two methods of assessing blood pressure.
UNIT SIX
COLD AND HEAT APPLICATION
Learning Objectives
• Describe various types of heat and cold application.
• Define important key terms related to the unit.
• Explain purposes of the procedures in the unit.
• Mention different devices used in hot and/ or cold application.
• Demonstrate skill for application as ordered or required.
Care of Patient with Fever

This includes sponging of the skin with alcohol or cool water for reducing
temperature
Solution: Tepid (luck – warm) water
Alcohol
• Part of alcohol to 3 parts of Luke warm H2O remove patient’s gown
• Take the patient temperature, sponge the body using the wash
cloth alternately, sponge each part 2-3 min. changing the was cloth
• Heat loss is by conduction or vaporization

• Check pulse frequently and report any change
Local Application of Heat and Cold

Heat and cold are applied to the body for local and systemic effects
Heat Application
Purpose
1. To relieve pain and muscles spasm – by relaxing muscles
- Increase blood flow to the area
2. To relieve swelling (facilitate wound healing)

- To relieve inflammation and congestion Heat
• Increases the action of phagocytic cells that ingest moisture

and other foreign material
• Increases the removal of waste products or infection

metabolic process
3. To relieve chilling and give comfort

Heat can be applied in both dry and moist forms
Dry Heat :- is applied locally, for heat conduction
• By means of a hot water bottle
Moist heat – can be provided, through conduction
• By compression or sitz bath
Cold Application
Purpose
• To relieve pain: cold decrease prostaglandin's, which intensify the
sensitivity of pain receptors, and other substances at the site of
injury by inhibiting the inflammatory processes
• To reduce swelling and inflammation: by decreasing the blood flow

to the area (vasoconstriction effect)
• Reduce raised body temperature due to fever

Cold can be applied in moist (cold compress 18-27 c) and dry form
(ice pack (bag) <15 oc)
Systemic effects of cold – extensive cold application can increase

blood pressure
Systemic effects of Hot – produce a drop in blood pressure –
excessive peripheral vasodilatation
Tepid Sponging
Definition: sponging of the skin with alcohol or cool water.
Purpose: to lower body temperature (fever)
Tepid (Luke –warm) water + alcohol
3 parts water: 1 part alcohol
The temperature of the water is 32 c (below body temperature) 27-37 –
alcohol evaporates at a low temperature and therefore removes body
heat rapidly
• Less frequently used – because alcohol causes skin drying

• Heat loss is by conduction and vaporization
• Determine the patients’ temperature, PR and RR frequently
Q 15 min
• Sponge each area (part) for 2-3 min changing the wash cloth
• The sponge bath should take about 30 minutes
• Reassess v/s at the end
• Discontinue the bath if the clients becomes pale or cyanotic
or shivers, or if the PR becomes rapid or irregular
Temperature of hot water bottle (bag) 52 o

c for normal adults,40.5 – 46
o
c– for debilitated (unconscious patients).
40.5-46 oc for children < 2 yrs;
Fill the bag about 2/3 full;
Expel the remaining air and secure the top;
Maximum effect occurs in 20-30 min;
The application is repeated Q2 – 3 hrs to relieve swelling compress – a
moist gauze or cloth immersed in (hot or cold) water and applied over an
area.
Local Application of Cold and Heat
Application of Cold
• Has systemic and local effect
• Can be applied to the body in two ways
1. Moist
2. Dry
Purpose: (Indication)
• To reducebodyto duringhighfeverandhyperpyrexiaor sun

stroke
• To relieve local pain
• To reduce subcutaneous bleeding e.g. in sprain and contusion
• To control bleeding e.g. epistaxis
• To relieve headache
• To provide comfort to a patient in extreme hot weather if

desired
1. Moist Cold
• Cold compress
• A cloth (padded gauze) is immersed in cold water and applied in

area where we get large superficial vessels E.g. axilla and groin
• Change the cloth when it becomes warm
• Applied for 15-20 min
2. Dry Cold (Ice Bag)
• Ice kept in a bag

• Covered with cloth and applied on an area
• Temperature <15 C
Application of Heat
Purpose
• To relieve stasis of blood
• To increase absorption of inflammatory products
• To relieve stiffness of muscle and muscle pain
• To relieve pain and swelling of a localized inflammation boil or

carbuncle – sometimes increases edema, increases capillary
permeability
• To increase blood circulation
• To promote suppuration
• To relieve distention and congestion
• To provide warmth to the body
Methods
1. Dry Heat
• Using hot water bottle (bags)
• After contactof the body with moistureof water vapors

o
temperature >46
C
o
• 52 C for normal adults
o
• 40.5– 46 C for debilitated or unconscious patient’s and child < 2
yrs
• 2/3 of the bag should be filled with water
• Expel the remaining air and secure the top
• Dry the bag and hold it upside down to test for leakage
• Wrap it in a towel or cover and place it on the body part
• Maximum effect occurs in 20-30 min
• Remove after 30-45 minutes
2. Moist Heat
1. Hot compress: a wash cloth immersed in hot water of temperature
40-46oc and change the site of washcloth frequently
Complication
• Paralysis
• Numbness
• Loss of sensation – fear of burn
2. Sitz bath
Sitz Bath (hit bath)
It is used to sock the client's pelvic area
• A clients sits in a special tub or a bowel
• The area from the mid things to the iliac crests or umbilicus -
increases circulation to the perineum (when the legs are also
immersed blood circulation to the perineum or pelvic area
decrease)
• Temperature of water – 40-43 C (105-110 F) – unless the patient is

unable to tolerate the temperature
Purpose:
• To relieve pain in post operative rectal condition
• Smoothen irritated skin (perineum)
• Facilitates wound healing (after episiotomy)
• To release the bladder in case of urinary retention
If it is going to be given in the tub – fill ½ the tube with water and add the
ordered medication
In a bowel – fill 2/3 of it with water – add the ordered medication and
dilute
The medication to Rx the perineum in KMNO4 sol. 250 mg KMNO4 in

500 ml of water
The duration of the bath is generally 15-20 minutes (20-25) depending on

the client’s health Help the client to dry
Study Questions
1. Mention the two purposes of the heat application.
2. Describe the mechanism of action of heat application to effect its

purposes.
3. What is tepid sponge?
4. What is the common medicine used in sitiz bath?

5. What is the average durationtime
of the patient is soaked in sitiz
bath?
UNIT SEVEN
ELIMINATION OF GASTROINTESTINAL AND

URINARY SYSTEM
Learning Objective
At completion of the unit the student will be able to:
• Define enema.
• List purposes of different types of gastric aspiration, lavage, enema
and catheterization.
• Mention types of enema.

• Provide enema according to its purpose and need.
• Explain mechanism of action of fluids used for enema.
• Identify important precautions of the procedure.
• Explain purpose of catheterization.
• Identify different types of catheters.
• Describe indication of catheterization.
• Demonstrate sterility technique through out the catheterization.
• Intervene the procedure for those in need of it with understanding
of both male and female patient.
I Gastric Lavage
Definition- This is the irrigation or washing out of the stomach.
Purpose
1. To remove alcoholic, narcotic or any other poisoning, which has
been swallowed.
2. To clean the stomach before operation

3. To relive congestion, there by stimulating peristalsis e.g. Pyloric

stenos is
4. For diagnostic purposes

1. Gastric Lavage Using a Simple Rubber Tube
Equipment:
Clean trolley.
• Bowel containing large esophageal tube in ice (cold water)
• Rubber tubing with screw or clip and glass connection
• Metal or plastic funnel
• Large Jug (5 litter)
• Solution as prescription/usually to care for acidic poisoning. We
use sodium bicarbonate 1 teaspoon to 500 cc. of water at a
temperature of 370c - 380c.)
• Small jug to carry solution to the funnel

• Lubricant e.g. liquid paraffin
• Bowl for gauze swabs
• Cape or protective material to put around the patient chest
• Pail to receive returned fluid
• Mackintosh or paper to protect the floor beneath the pail
• Receiver for used esophageal tube
• Paper bag for waste material • A tray for mouth wash after
lavage
• Denature cup.
• A receiver for pt's dentures. If any, and should be labeled with the
pt's name
• A receiver containing mount gag, tongue depressor, and tongue

forceps if patient is unconscious
• Mackintosh to protect bed linen

• Litmus paper
• Specimen battle. If laboratory test is requires

• Measuring jug
Procedure
1. Explain procedure to the pt and ask him/her to remove artificial
dentures, If any.
2. Protect pt with cape or towel

3. Protect bed linen by spreading the mackintosh on the accessible
side of the bed.
4. Place mackintosh or paper under the pail to protect the floor

5. Elevate head of the bed it pt is conscious and the condition
permits. But if unconscious, place in prone position with head over
the edge of the bed or head lower than the body.
6. Measure the tube from the tip of the nose up to the ear lobe and
from the bridge of the nose to the end of the sternum. (32 - 36
c.m.)
7. Gently pass the tube over the tongue, slightly to one side of the
midline towards the pharynx. (If patient is unconscious, mouth gug
may be used)
8. Ask patient to swallow while inserting the tube and allow to breath
in between swallowing.
9. If air bubbles, cough and cyanosis are noticed the tube is with
drawn and procedure commenced again.
10. After inserting, place funnel end in a basin of water to check if the
tube is in the air passage.
11. Fill the small pint measure and power gently until the funnel is
empty, then invert over the pail.
12. Take specimen. If required, and continue the process until the
returned fluid becomes clear and the prescribed solution has been
used.
13. Remove tube gently and give mouth wash

14. Measure the amount of fluid returned and record
15. Report and abnormality e.g. blood stain or clots or pieces of the
gut.
2. Gastric Lavage Using a Tube with a Bulb
1. Clamp tubing below bulb.

2. With right hand, squeeze bulb this forcing the air out through the
funnel.
3. Withlefthand,pinchtubingoverbulband at the sametime

releasing bulb. This createsion,
a suct
which will draw the stomach
contents in to the bulb.
4. Lower funnel and allow excess gastric contents to drain in to the
pail.
5. Pour200c.c - 300c.c g of solution
intofunnel.Beforefunnelis
empty invert it and allow solution to
6. drain. solutionstopsrunning,turnup funnelandadd another
Before
quantity of solution
7. Repeat this procedure until returns are clear
8. Gentlyremovethe tube,feelthe patientpulseand watchthe
respiration
N.B.
Record
• Time of treatment
• Amount & kind of solution used
• Nature of returned fluid
• Reaction of patient during and after procedure
II. GASTRIC ASPIRATION

• Aspiration is to withdrawal
d orofgas from a cavity by suction
flui
Purpose
1. To prevent or relieve distention following abdominal operation
2. In case of gastrointestinal obstruction, to remove the stomach or
gastric contents
3. To keep the stomach empty before on emergency Abdominal
operation is done
4. To aspirate the stomach contents for diagnostic purposes

There are two type of gastric Aspiration
1. Intermittent method: - In this case, Aspiration is done as condition

requires and as ordered.
2. Continues method: - Attached to a drainage bag
There are 2 ways of supplying suction

a. Simple suction by the use of a syringe
b. An electric suction machine
The continues method is indicated when it is absolutely necessary and
desirable to keep the stomach and duodenum empty and at rest.
Equipment
• Aspiration tube (Ryle's tube)
• Aspiration syringe if this method is used
• Gallipots with lubricant e.g. liquid paraffin or vase line, to lubricate
the nostrils
• Gauze swabs in a bowl

• Sodium bicarbonate solution or saline to clean the nostrils
• Litmus paper
• Water in a galipot to test the right position of the tube in the
stomach
• Two test tubes and laboratory forms of necessary

• Saline or plain water in a galipot to be injected, in case the
stomach content is too thick to come out through the syringe.
• Rubber mackintosh and towel to protect the patients chest.

• Receiver for sailed swabs
Procedure
1. Explain procedure to patient, in order to gain her/his co-operation
2. Prop up in an upright position with help of back rest and pillow
3. Cleanse and lubricate the nostrils
4. Lubricate the Ryle's tube with water
5. Insert the tube as directed in nasal feeding and ask the patient to
swallow as the tube goes down.
6. Instruct patient to open her or his mouth to make sure the tube is
in the stomach
7. After being sure that the tube is in the right position, inject about
15-20 cc. of saline or water in to the stomach.
8. Draw plunger back to with draw the fluid collect specimen, If

needed
9. If the Ryle's tube is to be left in site then a spigot or clamp is used

to close the end, but if it is for one aspiration and to be removed
immediately, it should be withdrawn very gently to avoid irritating
the mucous lining.
N.B
1. Special care of the nose and mouth to prevent dryness should be
considered
2. Always measure the amount withdrawn accurately noting color,

contents and small
3. Record on the fluid chart properly

4. Report any change in patient condition regarding pulse,
Temperature, B.P fluid out put.
III. Enema
Enema: is the introduction of fluid into rectum and sigmoid colon for
cleansing, therapeutic or diagnostic purposes.
Purpose:
• For emptying – soap solution enema the cloth
• For diagnostic purpose Barium enema
• For introducing drug/substance (retention enema)
Mechanisms of some solutions used in enema

1. Tap water: increase peristalsis by causing mechanical distension
of the colon.
2. Normal saline solution
3. Soap solution: increases peristalsis due to irritating effect of soap

to the lumenal mucosa of the colon.
4. Epsum salt: The concentrated solution causes flow of ECF to the
lumen causing mechanical distension resulting in increased
peristalsis.
Classified into:
 Cleansing (evacuation)
 Retention
 Carminative
 Return flow enema
Cleansing enema is of two kinds:

1. High enema
 Is given to clean as much of the colon as possible
 The solution container should be 30-45 cm about the rectum
2. Low enema
 Is administered to clean the rectum and sigmoid colon only
Guidelines
o o
Enema for adults are usually given catand
40-43
for children at c37.7
High – cause injury to the bowel mucous
Cold – uncomfortable and may trigger a spasm of the sphincter muscles
The amount of solution to be administer depends on:

Kind of enema
 To soften feces and lubricate the rectum and colon

 To clean the rectum and colon in preparation for an examination.
E.g. Colonoscopy
 To remove feces prior to a surgical procedure or a delivery
 For incontinent patients to keep the colon empty
 For diagnostic test
E.g. before certain x-ray exam – barium enema
Before giving stool specimen for certain parasites
Age Amount
18month 50-200 ml
18mon-5 yrs 200-300 ml
5-12yrs 300-500 ml
12yrs and older 500-1,000 ml
The rectal tube should be appropriate: is measured in French scale
Age Size
Infants/small child 10-12fr
Toddler 14-16 fr
School age child 16-18fr
The age of the person and
The persons ability to retain the solution
Purpose
To stimulate peristalsis and remove feces or flatus (for
constipation)
Adults 22-30 fr
Solution used:
1. Normal solution
2. Soap solution – sol. Soap 1gm in 20 ml of H2O

3. Epsum salt 15 gm – 120 gm in 1,000 ml of H 2O Cleansing Enema
Procedure
Inform the patient about the procedure
Put bed side screen for privacy
Attach rubber tube with enema can with nozzle and stop cock or
clamp
Place the patient in the lateral position with the Rt. leg flexed, for
adequate exposure of the anus (facilitates the flow of solution by
gravity into the sigmoid and descending color, which are on the
side
Fill the enema can which 1000 cc of solution for adults

Lubricate about 5 cm of the rectal tube – facilities insertion through

the sphincter and minimizes trauma
Hung the can = 45 cm from bed or 30 cm from patient on the stand

Place a piece of mackintosh under the bed
Make the tube air free by releasing the clamp and allowing the fluid
to run down little to the bed pan and clamp open – prevents
unnecessary distention
Lift the upper buttock to visualize the answer

Insert the tube
¾ 7-10 cm in an adult smoothly and slowly
¾ 5-7.5 cm in the child
¾ 2.5-3.75 cm in an infant
Note: if resistance is encountered at the internal sphincter, ask the

clients to take a deep
Breath, then run a small amount of solution (relaxes the internal anus
sphincter)
Raise the solution container and open the clamp to allow fluid to
flow
Administer the fluid slowly if client complains of fullness or pain

stop the flow for 30” and restart the flow at a slower rate –
decreases intestinal spasm and premature ejection of the solution
Do not allow all the fluid to go as there is a possibility of air

entering the rectum or when the client can not hold anymore and
wants to defecate, close the clamp and remove the rectal tube
from the anus and offer the bed pan.
Remove bed pan and clean the rectal tube
Retention Enema
Administration of solution to be retained in rectum for short or long

period
Purpose
To supply the body with fluid.
To give medication E.g. stimulants – paraldehyde or antspasmodic.
To soften impacted fecal matter.

The tube for retention enema is smaller.
Procedure
Similar with the cleansing enema but the enema should be administered
very slowly and always be preceded by passing a flatus tube
Note
1. Most medicated retention enema must be preceded by a cleansing
enema. A patient must rest for ½ hrs before giving retention enema
2. Elevate foot of bed to help patient retain enema

3. The amount of fluid is usually 150-200 cc
4. Temperature of enema fluid is 37.4 oc or at body
5. Kinds of solution used to supply body with fluid are plain H 2O,
normal saline, glucose 5% sodabicarbonate 2-5%
6. Olive oil 100-200 cc to be retained for 6-8 hrs is given for server
constipation
Retention Enema
 Are enemas meant for various purpose in which the fluid usually
medicine is retained in rectum for short or long period – for local or
general effects E.g. oil retention enema
Antispasmodic enema
1. Principles:
• Is given slowly by means of a rectal tube

• The amount of fluid is usually 150-200 cc
• Cleansing enema is given after the retention time is over
• Temperature of enema fluid is 37.4 c or body
(Return flow Enema) Harris fluid
Rectal Wash Out (Siphoning An Enema)

(Colon irrigation or colonic flush)
- Also called enterolysis
- Is the process of introducing large amount of fluid into large bowel
for flushing purpose and allow return or wash out fluid
Purpose
• To prepare the patient for x-ray exam and sigmoidoscopy
• To prepare the patient for rectum and color operation
Solution Used
• Normal saline
• Soda-bi-carbonate solution (to remove excess mucus)
• Tap water
• KMNO4 sol. 1:6000 for dysentery or weak tannic acid
• Tr. Asafetida in 1:1000 to relieve distention Amount of solution
• 5-6 liters or until the wash out rectum fluid becomes clear
Procedure
• Insert the tube like the cleansing enema
• The client lies on the bed with hips close to the side of the bed
(client assumes a right side lying position for siphoning)
• Open the clamp and allow to run about 1,000 cc of fluid in the
bowel, then siphon back into the bucket
• Carry on the procedure until the fluid return is clear

Note:
• The procedure should not take > 2 hrs
• Should be finished 1 hr before exam or x-ray – to give time for the
large intestine to absorb the rest of the fluid
• Give cleansing enema ½ hr before the rectal wash out

• Allow the fluid to pass slowly
Passing a Flatus Tube
Purpose
• To decrease flatulence (sever abdominal distention)
• Before giving a retention enema
Procedure
• Place the patient in lt. Lateral position
• Lubricate the tube about 15 cm

• Separate the rectum and insert 12-15 cm in to the rectum and tape
it
• Connect the free end to extra tubing by the glass connector
• The end of the tube should reach the (tape H 2O) solution in the
bowel
• The amount of air passed can be seen bubbling through the

solution
(a funnel may be connected to free end of tube and placed in an

antiseptic solution in bowel)
• Teach client to avoid substances that cause flatulent

• Leave the rectal tube in place for a period or no longer than 20 –

can affect the ability to voluntarily control the sphincter if placement
is prolonged
• Reinsert the rectal tube Q 2-3 hrs if the distention has been
unrelieved or reaccumulates – allows gas to move in the direction
of the rectum.
IV. Urinary Catheterization
Definition of catheterization: Is the introduction of a tube (catheter)

through the urethra into the urinary bladder
• Is performed only when absolutely necessary

• Fear of infection and trauma
Note. Strictly a sterile procedure, i.e. the nurse should always follow
aseptic technique
Catheter: is a tube with a hole at the tip

Equipment
I. Sterile
• Kidney dish
• Gall pot
• Gauze • Towel
• Solution
• Lubricant
• Catheter
• Syringe
• Water
• Specimen bottle
• Gloves
II. Clean
• Waste receiver
• Rubber sheet
• Flash light
• Measuring jug
• Screen
Selecting an appropriate catheter:
• May be made of
⇐ Plastic – for 1 week
⇐ Latex – 2-3 (rubber)

⇐ Silicon – for 2-3 month
⇐ Pelyvinylchloride (PVC) – 4-6
1. Select the type of material in accordance with the estimated length

of the catheterization period:
- Are sized by diameters of the lumen

- Graded on French scale or numbers
2. Determine appropriate catheter size

• Catheter size depends on the size of the urethral canal ⇐ # 8-

10 Fr – children
⇐ # 14-16 Fr – female adults
⇐ # 18 Fr – adult male
3. Determine appropriate catheter length by the clients gender
• For adult male – 40 cm catheter
• For adult females – 22 cm catheter
4. Select appropriate balloon size
• 5 ml – for adults
• 3 ml – for children
Types of Catheter
1. Straight (plain or Robinson)
2. Retention (Foleys, indwelling)
Catheterization Using a straight catheter
Purpose
• To relieve discomfort due to bladder distention
• To assess the anti of residual urine
• To obtain a urine specimen
• To empty the bladder prior to surgery
Procedure
• Prepare the client and equipment for perennial wash
• Position the patient – dorsal recumbent (pillows can be used to
elevate the buttocks in females).
• Drape the patient.
Dorsal Recumbent
Female - for a better view of the urinary meatus and reduce the risk of
catheter contaminate.
Male- allows greater relaxation of the abdominal and perennial muscles

and permits easier insertion of the tube.
Straight Catheter: is a single lumen tube with a small eye or opening

about (1.25 cm) from the insertion tip:
• Wash the perennial area with warm water and soap

• Rinse and dry the area
• Prepare the equipment
• Create a sterile field • Drop the client with a sterile drape
• Clean the area with antiseptic sol.

• Lubricate the insertion tip of the catheter (5-7 cm in)
• Expose the urinary meatus adequately by retracting the tissue or
the labia minora in an upward direction – female
• Retract the fore skin of uncircumcised mal.

• Grasp the penis firmly behind the glans and hold straighten the
down ward curvature of vertical it go to the body – male hole the
catheter 5 cm from the insertion tip
• Insert the catheter into the urethral orifice

• Insert 5 cm in females and 20 cm in males or until urine comes
• Collect the urine – for specimen (about 30 ml)
• Pinch previous leakage
• Empty or drain the bladder and remove the catheter
• For adults experiencing urinary retention an order is needed on the
amount to urine to be expelled
Note.
• If resistance is encountered during insertion, do not force it –

forceful pressure can cause trauma. Ask the client to take deep
breaths - relaxes the external sphincter (slight resistance is normal)
Inserting a Retention (Indwelling) Catheter

Purpose
• To manage incontinence
• To providefor intermitten
or continuous
bladderdrainageand
irrigation t
• To prevent urine from contacting an incision after perineal surgery

(prevent
information)
To measure urine out put needs to be monitored hourly
•
Procedure
• Explain the procedure to the patient
• Preparethe equipment
like the straightcatheterization
and
retention catheter
⇐ Syringe
⇐ Sterile water
⇐ Tape
⇐ Urine collection bag and tubing

Retention (Foley) Catheter
• Containsa second,smallertubethroughoutits lengthon the

inside – this tube is connected to a balloon near the insertion tip.
• After catheter insertion, the balloon is inflated to hold the catheter
in place with in the bladder.
• The out side end of the catheter is bifurcated i.e, it has two
openings, one to drain the urine, the other to inflate the balloon.
• The balloons are sized by the volume of fluid or air used to inflate
them 5 ml – 30 ml (15 commonly) indicated with the catheter size
18 Fr – 5 ml.
• Test the catheter balloon

• Follow steps as insertion straight catheter
• Insert the catheter an additional 2.5 – 5 cm (1-2 in) beyond the
point at which urine began to flow (the balloon of the catheter is
located behind the opening at the insertion tip) – this ensures that
the balloon is inflated inside the bladder and not in the urethra
(cause trauma)
• Inflate the balloon with the pre filled syringe
• Apply slight tension on the catheter until you feel resistance:
resistance indicates that the catheter balloon is inflated
appropriately and that the catheter is well anchored in the bladder
• Release the resistance

• Tape the catheter with tape to the inside of a females thigh or to
the thigh or a body of a male client
⇐ Restricts the movement of the catheter and irritation in the

urethra when the client moves
⇐ When there is increased risk of penile scrotal excoriation

• Establish effective drainage
• The bag should be off the floor – the emptying spout does not
become grossly contaminated
• Document pertinent data
Removal
• Withdraw the sol. From the balloon using a syringe
• And remove gently
Study Questions
1. Define gastric lavage.

2. Mention indications of gastric lavage.
3. Define Enema.
4. State how the mechanism
tion
of of
ac soap solution enema exerts
its function.
5. Describe the difference between male and female catheterization.
UNIT EIGHT
MEDICATION ADMINISTRATION
Learning Objectives
At the end of this unit the students will be able to:
 Describe various rout
of drug administration.
 Mention the general rules &
ofcare
administering medications.
 Identify the parts and types of syringes and needles.
 List the necessary equipments required for drug administration.
 Locate the different sites of parentral drug administration.
 Demonstrate essential steps
of medication administration.
 List precautions for medication administration
Different Routes of Drug Administration

 Oral
 Topical
 Parentral
- Intradermal
- Subcutaneous
- Intramuscularly
- Intravenous
 Rectal
 Vaginal
 Inhalation
I. Oral Administration
Definition: Oral medication is drug administered by mouth
Purpose
a. When local effects on GI tract are desired
b. When prolonged systemic action is desired
Disadvantages and Contra- indications
1. For a patient with nausea & vomiting, unconscious patients.

2. When digestive juices inactivate the effect of the drug.
3. When there is inadequate absorption of the drug, which leads to
inaccurate determination of the drug absorbed.
4. When the drug is irritating to the mucus membrane of the

alimentary canal.
Type of Oral Medication
1. Lozenges (troches) - sweet medicinal tablet containing sugar

that dissolve in the mouth so that the medication is applied to the
mouth and throat
2. Tablets - a small disc or flat round piece of dry drug

containing one or more drugs made
by compressing a powdered form of
drug(s)
3. Capsules - small hollow digestible case usually

made of gelatin, filled with a drug to be swallowed by the
patient.
4. Syrups - sugar containing medicine dissolved in

water
5. Tinctures - medicinal substances dissolved in water

6. Suspensions - liquid medication with undissolved solid
particles in it.
7. Pills and gargle - a small ball of variable size, shape and

color some times coated with sugar that contains one or more
medicinal substances in solid form taken in mouth.
8. Effervescence - drugs given of small bubbles of gas.
9. Gargle - mildly antiseptic solution used to clean

the mouth or throat.
10. Powder - a medicinal preparation consisting of a

mixture of two or more drugs in the form of fine particles.
Equipment
• Tray
• Towel
• A bowl of water for used mediation cup
• Measuring spoon
• A Jug of water (boiled water)
• Chart and medication card
• Ordered medication
• Straw if necessary
Procedure
• Prepare your tray and take it to the patient's room
• Begin by checking the order
• Read the label 3 times
• Place solution and tablets in a separate container.
• If suspension, shake the bottle well before pouring
• Take it to the pt's bedside
• Keep the medication in site at all time
• Identify the pt. carefully using all precautions. (Pt’s name, bed
number…)
• Remain with the pt. until each medicine is swallowed
• Offer additional fluid as necessary unless contra-indicated
• Record the medication given, refused or omitted immediately.
• Take care of the equipment & return them to their proper places.
• Wash your hands.
Note
1. Remember the 5 R's  Right patient
Right medication
Right route
Right dose
Right time
2. Always keep the bottle tightly closed.
3. Clean and keep the label of the bottle clear.
4. Keep medication away from light.
5. Cheek their expiration date.
6. Keep the rim of the bottle clean.
7. Give your undivided attention to your work while preparing and
giving medications.
8. Make sure that a graduate nurse checks some potent drugs.

9. Never give medications from unlabeled container
10. Never return a dose once poured from the bottle.
11. Check your patient's vital sign may be necessary before and after
administrating some drugs e.g. digitals, ergometrine.
12. Never give medicine that some one poured or drawn.

13. Never leave medicine at bed side of a patient and within reach of
the children
II. Suppository
Purpose
• To produce a laxative effect. (bowel movement),suppository is
used frequently instead of enema since it is inexpensive.
• To produce local sedative in the treatment of hemorrhoids or rectal

abscess.
• To produce general sedative effects when medications cannot be

taken by mouth
• To check rectal bleeding
Equipment
• Suppository (as ordered) • Gauze square
• Rectal glove or finger cot

• Toilet paper
• Receiver for soiled swabs
• Bedpan, if the treatment is in order to produce defection.
• Screen
• Mackintosh and towel
Procedure
• Screen the patient
• Lie patient on left lateral position or If not possible on dorsal
recumbent position.
• Towel and mackintosh is placed under the buttocks.

• Fold back top linen to the opposite side thus exposing the buttocks
only
• Put on the glove and insert the suppository into the rectum until it is
felt to slip beyond the internal sphincter muscle.
• Hold the buttocks together for a few minutes until there is no longer
desire to expel the suppository.
• Clean the anus with a toilet paper and place it in the receiver for
used swabs.
• Report the time, type, result of the treatment and the reaction of
the patient to the treatment.
• Wash and boil glove for 10 minutes and return to proper place.
Kinds of Suppositories Used:

1. Bisacodyl (Dulcolax) is commonly ordered for its laxative action. It

stimulates the rectum and lubricates its contents. Normally 15
minutes is needed to produce bowel movement.
2. Glycerin or suppository for bringing about bowel movement. If soap

suppository is used cut a splinter of soap 2-6 cm. loch and wash it
in hot water to smooth the rough edges before administration.
3. Bismuth - for checking diarrhea.

4. Opium, sodium barbital etc. for sedation
III. Parentral Drug Administrationa
A. Intradermal Injection
Definition:It is an injection given into the dermal layer of the skin

(corneum)
Purpose
For diagnostic purpose
a. Tine test ( mantoux test )
b. Allergic reaction
c. Intradermal injection may also be given for therapeutic purpose
Site of Injection
• The inner part of the forearm (midway between the wrist and
elbow.
• Upper arm, at deltoid area for BCG vaccination
Equipment
• Tray
• Syringe & needle (sterile)
• Receiver
• Drug (to be injected)
• File - Alcohol swab
• Marking pen
• Water in the bowel to rinse syringe and needle
Procedure
• Take equipment to the patient's side
• Explain procedure to patient
• Get hold of the arm & locate the site of injection.
• Clean the skin with swab and inject the drug about 0.1. 0.2 inch in
to the epidermis after the bevel of the needle is no longer visible.
Don't massage the site.
• Check for the immediate reaction of the skin (10-15 minutes later
for tetanus, 20-30 minutes later for penicillin)
• If it is for tine test, mark the area

• Chart the data and time of the administration of the drug.
• Take care of the equipment & return to their places.
• Do not forget to do the reading after 72 hours if it is for tine test
(tuberculin test)
B. Sub - Cutaneous Injection
Definition: Injecting of drug under the skin in the subcutaneous tissue,
(under the dermis)
Purpose:
• To obtain quicker absorption than oral administration
• When it is impossible to give medication orally
Equipment
• Tray
• Sterile syringe & needle
• Forceps in a container
• Alcohol swabs
• Medication
• File
• Medication chart
•
Receiver
• Water in a bowel
• Disposing box
Site of Injection
• Outer part of the upper arm
• The abdomen below the costal margin to the iliac crest.
• The anterior aspect of the thigh
Procedure
• Take equipment to the pt's bed side or room
• Draw your medication
• Expel the air from the syringe
• Clean the site (usually it is in upper arms, thighs or abdomen)
• Grasp the area between your thumb & forefinger to tense it.
• Insert the needle elevate about 450 - 600 angle.
• Pierce the skin quickly & advance the needle
• Aspirate to determine that the needle has not entered a blood
vessel
• Inject the drug slowly.

• After injecting withdraw the needle and massage the area with
alcohol swab.
• Chart the amount and time of administration immediately.

• Take care of the equipment- wash, sterilize and return to its place
• Watch for undesired reaction (side effect of the drug) etc.
Note.
If repeated injections are given, the nurse should rotate the site
of injection so that each succeeding injection is about 5 cm
away from the previous one.
C. Intera- Muscular Injection
Definition: It is an introduction of a drug into a body's system via the

muscles.
Purpose
• To obtain quick action next to the intravenous route
• To avoid an irritation from the drug if given through other route.
Equipment
• Tray
• Ordered drug (ampoule, vial)
• Sterile syringes and needle in a container
• Alcohol swab
• Receiver
• A bowl of water for used syringes and needle
• File
• Sterile jar with sterile forceps
• Chart
Sites for I.M. Injection

• Ventrogluteal muscle
• Dorsogluteal muscle
• Deltoid muscle
• Vastus Lateralis
Procedure
• Do the ABC of the procedure.
• Prepare tray & take it to the pr's room
•
• Prepare the medication
• Draw the medicine
• Expel the air from the syringe
Choose the site of injection (the site for intra- muscular)

• Using the iliac crest as the upper boundary divided the buttock
into four. Clean the upper outer quadrant with alcohol swab:
• Stretch the skin and inject the medicine

• Draw back the piston (plunger) to check whether or not you are in
the blood vessel ( if blood returns, withdraw and get a new needle
& reinject in a different spot)

• Push the drug slowly into the muscle
• When completed, withdraw the needle and massage the area with
swab gently to and absorption.
• Place the patient comfortably

• Take care of the equipment you have used & return to their places
• Chart the amount, time route and type of the medicine
• Check the patient's reaction
Note:
1. The needle for i.m. Injection should be long
2. Other sites for I.M Injection is the deltoid muscle and the outer
part of the thigh (quadriceps muscle)
3. Strict aseptic technique should be observed throughout the

procedure.
D. I.V. INJECTIONS
Definition: It is the introduction of a drug in solution form into a vein.

Often the amount
is not more than 10.ml. at a time.
Purpose
• When the given drug is irritating to the body tissue if given through
other routes.
• When quick action is desired.

•
When it is particularly desirable to eliminate the variability of
absorption.
• When blood drawing is needed (exsanguinations)
Equipment
• Tray
• Towel and rubber sheet

• Sterile needle and syringes in a sterile container
• Sterile forceps in a sterile container
• Alcohol swabs
• File
• Medication
• Tourniquet
• Receivers (2)
• Treatment Chart
• Glove
Procedure
• Prepare your tray & the medication
• Position the patient properly
• Place rubber and towel under his arm(to protect the bed linen)
• Expose the arm and apply tourniquet
• Ask pt. To open and close his fist.
• Palpate the vein and clean with alcohol swab the site of the
injection (Which is mainly the mid cubital vein of the arm)
• Clean with a circular motion, proceed from center of the site
outward.
• Hold the needle at about 450 angles in line with the veins.
•
• Puncture the vein and draw back to check whether you are in the
vein or not.
(Blood return should be seen if you are in the vein)

Once you know that you are in the vein, release the tourniquet and
gently lower the angle of the needle
• When it is nearly paralleled to the vein and instill the medications.

Give very slowly unless there is an order to give it fast (Normally
40-60 drops is given in 1 minute).
• Check the pt's pulse in between. Any complaint from the patient
should not be ignored.
• Apply pressure over the site after removing the needle to prevent
bleeding. Tell patient to flex his elbow.
• Watch the patient for few minutes before leaving him.

• Remove your equipment
• Put the pt. In a comfortable position
• Wash, sterilize and place the equipment in order.
• Chart the medication given the amount, time & the reaction of the
pt.
Note:
1. Have a bowl of water to rinse the needle used immediate
2. Make yourself as well as the pt. Comfortable before giving
injection.
3. It is the fastest way of drug administration

4. Never recup a used needle
E. Intravenous Therapy
Definition: It is the administration of a large amount of fluid into the

system through a
•
vein.
Purpose
• To maintain fluid & electrolyte balance
• To introduce medication particularly antibiotics.
Equipment
• IV fluid as ordered
Sterile syringe & needle
• Rubber & towel
• Receiver
• Alcohol swabs
• Arm board
•
• Bandage & scissors
• Tourniquet
• I.V pole
• Adhesive tape
• Medication chart
Preparation of the Patient
Since an infusion therapy takes several hours to complete, the patient

should first be made conformable.
Procedure
• Take equipment to the patient's bedside
• Explain to the chart. Be sure you have right patient.
• Remove air form the tubing
• Place rubber & towel under the arm
• Apply tourniquet aboutabove
3 the intended site of entry.
c.m.
Observe & palpate for suitable vein
•
• Cleanse the skin with alcoho
l swabs thoroughly & place the swab
used thumb the
retract down the vein & soft tissue 4 c.m. below the intended site of
injection.
0
• Hold needle at angle
45 line with the vein
• Pierce the skin and puncture the vein
• Check if you are in the vein by drawing back with the syringes.
(blood returns if you are in the vein)
• Release the tourniquet gently
• Start the flow of solution by opening the clamp.
Support needle with sterile gauss or sterile cotton balls
• If necessary to keep it in proper position in the vein
• Anchor the I.V. tubing with the adhesive tape to prevent pull on the
needle.
•
• Place arm board or splint under the arm and bandage around.
• Adjust the rate of flow
• Rate of flow is regulated by the following formula.
Number of ml. of sol's number of drops in a ml.

Number of hrs. over which sol. is to be administered x 60 minutes
1ml = 15 drops
E.g. if 1000ml of 5% D/w is to run for 24 hrs, how many drops per
minutes should it run?
1000 ml. x 15 gtt/ml. = 1000 x 15 gtt. = 10 gtt/min

24 x 60 min. 24 x 60 min.
Note:
1. The arm board should be long enough to extend beyond the wrist
and elbow joint.
2. Board should be padded

3. Infusion bottle should be labeled with the date, time infusion is
started, drops per minute, and any added medications. If more
than one bottle as used in 24 hrs, it should be labeled as bag
1,2,3, and so on.
4. Extend the arm in the most comfortable position.

5. Usual areas used for intravenous infusion are:
a) The median basilica vein on the inner surface of the arm.
b) A vein on top of the foot
c) In an infant the jugular vein and the scalp vein
F. Blood Transfusion
Definition: It is the giving of blood to a patient through a vein
Propose
• To counteract severe hemorrhage and replace the blood loss.
• To prevent circulatory failure in operation where blood loss is
considerable, such as in rectal resection hysterectomy and arterial
surgery.
• In severe burns to make up for blood lost by burning but only after
plasma and electrolytes have been replaced.
• For severe anemia from cancer, marrow aplasia and similar
conditions.
• To provide clotting factors normally present in blood, which may be
absent as a result of disease.
Equipment
• Bottle containing blood, with the patient name, blood group and
Rh. Factor.
• Blood giving set
• Sterile forceps in a sterile jar
• Sterile syringes and needle
• Alcohol swabs
• Sterile gauze
• Rubber sheet and towel
• Tourniquet
• Arm splint
• Bandages and scissors
• Adhesive tape
• Receiver for dirty swabs
• I.V pole (stand)
• Patient's chart.
•
Procedure
Before blood transfusion is administered the nurse has to check
the blood group & RH- factor, if cross match of the donor's & the
recipient’s blood is done and is compatible. Also check for HIV.
• Prepare the tray with necessary items

• Before taking it to the patient's room check the patient's name,
hospital number, bed number, blood group, Rh. Factor and the
expiration date with a 2nd number, blood group, Rh-factor and the
expiration date with a 2nd nurse or a doctor.
• (Blood should be used within 21 days of its withdrawal date)

• Take it to the pt's room
• Hang the bottle & remove the air from the tubing
• Put pt. in a comfortable position.
• Place rubber & towel under the arm
• Check the vital signs before administering
• Choose the vein • Apply tourniquet
• Clean the skin & feel for a distended vein & clean again.
• Puncture the vein with the needle (the needle here should be
short and wide so that it does not cause occlusion easily)
• After you make sure that you are in the vein release tourniquet &
open the lamp.
• The drop/minute at the beginning should be very slow

• Watch patient closely for any reaction
• If there is no reaction from the patient regulate the rate of flow
according to the patient's conditions & the order.
• Splint the arm & position it comfortably.

• Remove the equipment you have used, wash and return to its
proper place.
•
• Record the time you started the blood & any other pertinent
information.
Check pt. frequently.
Note:
1. Always member to have anti- histamine injection ready in case a
patient has reaction from the blood.
2. Be familiar with the most usual symptoms of blood reactions which
are:-
Immediate Reaction:
a) Headache
b) Backache
c) Chills
d) Pyrexia
e) Rash of the skin (urticaria )
Late Reaction
a) Dyspnea
b) Renal shut down in severe cases
c) Heamaturia
d) Chest pain
e) Rigor (rigidity)
G. Cut Down
Definition Dissection
- of a vein for inserting I.V cannula or needle.
Purpose
 When vein puncture is difficult
 When pro longed, continuos infusion is needed
 When a secure infusion is essential
When rapid infusion is important
•
When emergency situation combine these indications.
Equipment
Sterile
Dressing forceps (1)
• Cotton balls in a gallpot
• Solution for cleansing
• Gloves
• Hole sheet (Fenestrated towel)
• Syringe and needle
• Scalpel (surgical knife)

• Mosquito forceps (3)
• Aneurysm needle (1)
• Silk
• Intravenous cannula or vein flow (2)
• Small, straight scissors (1)
• Small, curved scissors (1)
• Needle holder (1)
• Round needle (1)
• Cutting needle (2)
• Tissue forceps (1)
• Gauze (slit at one end)
• Probe
• Fine dissecting forceps (1)
• Local anesthesia
Clean
• Receiver of dirty swab
• Stand light, if available
• Adhesive tape (plaster)
• Dressing scissors
Procedure
•
• Bring equipment to the bedside of the patient
• Explain procedure to the patient
• Shave the area, if needed
• Position the patient properly
The nurse will then open the set and pour the cleaning lotion in to
the galipot for the doctor
• The doctor then scrub his hands, put on gloves, clean and drape
the area, he will insert the I.V
• The channel is securely tied with silk and skin is closed

•
• The nurse dresses the site and secure it with adhesive plaster
• Remove all equipment, wash
and send for
sterilization
H. Inhalation
Definition: Inhalation is the act of drawing in of gas vapor or steam

into the lungs for
therapeutic purposes It could be in dry, moist or vapour
form.
i. Oxygen Administration
:
Purpose
To provide and maintain a normal supply
2 for blood,
of o and tissues
2 o
may be administered in three ways.
1. By mask
2. Nasal Catheter
3. Tent.
1. Giving O2 by mask
There are many kinds of masks used
2 administration
for O the
common ones are:
1. The venture mask
2. The B.L.B. mask ( Boothby. Lovelace & Bulbulain)
The venture mask gives a controlled amount of O 2 i.e. it is not high to

cause respiratory depression & it is sufficient to relieve anoxia. It gives
24-35% of O2
The B.L.B mask provides an oxygen concentration of 90% with the flow
meter set at 7 liters/minute. This kind of mask allows the patient to eat,
drink and to expectorate. If the patient cannot breath through his nose,
the B.L.B mask should not be used.
Equipment
- A cylinder of O2 with a reducing value and pressure tubing to be
connected with the O2 cylinder.
- Mask
- Safety pin to secure the tubing to the bed linen
- Tissue paper to clean the nostrils with. If the patient is
unconscious, a tray containing a galipot of saline or water, wooden
applicator and receiver for soiled applicator is necessary in order to
clean the nostrils
Procedure
1. The adjustment is turned on before bringing the cylinder to the
bedside.
2. Explain treatment to pt.

3. Bring equipment to the bedside
4. Ask him to clean his hostels to avoid obstruction (if well enough)
5. Connect the mask to tubing and open the fine adjustment to the
required rate of flow. Then apply the mask to the patient's face
making sure that it rests comfortably on the pt's face. See that the
tubing is secured to the bed linen by means of safety pin. Stay with
the patient till he is reassured if it is his first time to be on oxygen
therapy.
2. Giving oxygen by nasal catheter.
There are different kinds of catheters, a)

A fine catheter
b) A spectacle frame, which carries two, places of rubber tubing and

is worn by the pt.
c) Two soft rubber catheters connected by y shaped connection to the

tube on O2 apparatus.
Equipment
- Oxygen cylinder with regulating valve and pressure tubing
- Wolf’s bottle
- Glass connection
- Fine catheters, lubricant, plaster
- Safety pin
- Tray containing a. galipot of saline or water. Receiver for soiled
applicators.
Procedure
1. Procedure is the same as giving oxygen by mask:
(procedure 1-4)
2. Connect the fine catcher with the pressure tubing. Turn on the fine
adjustment to the required rate of flow the maximum liter flow being
6-7 litter /minute.
3. Catheter is lubricated preferably with water and passed backward

into pharynx till the tip of the catheter is opposite the uvula. The
catheter can also be inserted by measuring the distance from the
patient's nose to his ear lobe. It is then taped in place. Never force
catheter against an obstruction.
Note:
Oxygen catheter are removed every 8 hrs. and a clean catheter is

inserted into the other nostril. Pt.'s receiving oxygen by catheter requires
special mouth and nose care since the catheter tends to irritate the
mucous membrane. There which stimulating secretions must remove.
Oxygen dries and irritates mucous membrane, therefore, should be
passed through water (Humidified) before it is administered by catheter.
The advantage of administration of oxygen by catheter is the freedom of
movement that it gives to patients receiving oxygen.
By this method patient can obtain about 50% concentration of oxygen.
3. Oxygen tent
Purpose:
a) To keep patient in high oxygenation environment.
b) Whenever the other means are not possible.
Equipment
1. Transparent oxygen tent and its apparatus fitted with oxygen
2. Ice if the apparatus is with out refrigerator device.
3. Hanger for the tent
4. Room thermometer if needed
5. No smoking sign for the unit
Procedure
1. Remove all electrical appliance from the room as this may produce
sparks.
2. Post sign of no smoking on many places in the unit

3. Prepare and check if the applicator is working properly.
4. Bring the oxygen unit to the bedside and fix the tent on the hanger.
5. Close all appliances of the tent: place ice if the apparatus is without
refrigeration device.
6. Tuck the side of the hold of tent under the mattress as far as they
will go.
7. Fill the tent with 12-15 liters of oxygen 40-60% concentration for
the first half hour.
8. After the first half hour regulate the flow of oxygen to 6-10 liters or
as ordered by the doctor until the treatment is completed.
9. Check temperature indicator frequently and adjust to 18 0C-220C.

10. Record state of patient and time started and the flow of the oxygen.
Precautions to be Taken When Oxygen is Used

1. Oxygen supports combustion. There fore it is essential for the
patient's safety their is no smoking within 3 meters of oxygen
equipment. Lighted matches, cigarettes, electric lights, nylon
clothing, electric pads, bells mechanical toys should be forbidden.
2. Alcohol must not be applied to the pt's skin

3 The catheter tip and the cylinder itself must not be lubricated with
Vaseline or oil or any kind
6. Cylinders must be handled carefully as the oxygen is under
pressure.
7. The fine adjustment should always be closed when the main tap is
turned on.
8. Check that there is no obstacle in the pt's airway before firing

oxygen in order to prevent pt. From suffocation.
9. The doctor will order the rate of flow. A rate of 2-liters/ minute is
commonly used when oxygen is used in case of emergency minute
is commonly used when oxygen is used in case of emergency
instead of free air. In the case of asphyxia liter/min may be needed.
Protect pt. from asphyxia ion inspecting regularly pressure gauge

and flow meter and noting pulse, respiration, color, mental state and
necrosis from carbon dioxide. ii. Steam Inhalation
Definition: It is the intake of steam alone or with medication through the

nose or mouth
Purpose
1. In order to produce a local effect on the upper respiratory passage
during cold, sinusitis, laryngitis, bronchitis etc. common drugs used
are frier balsam (tincture of benzoin compound, eucalyptus.
Menthol, camphor)
2. To allay spasm e.g. Asthma, angina pectoris
3. To increase circulation in the lungs by increasing or decreasing the

secretion of the bronchi.
E.g. ammonia inhaled in cases of fainting and syncope stimulated

the respiratory center and heart action.
4. To moisten secretions e.g. Tracheotomy
There are two Types of Inhalation

1. Intermittent (interrupted) e.g. Nelson's inhaler.
2. Continues method e.g. steam tent.
1. Nelson's Inhaler
Equipment
• Nelson's inhaler with the mouth piece
• Cover for the inhaler (blanket or towel)
• A bowl or saucepan to carry the inhaler with
• Face towel to wipe the face as patient required
• Gauze can be use around the moth piece to prevent burning of the
lips.
• A tray. Large enough, to carry the inhaler to take it to the bedsides.

• A measuring jug with water which is 820C
• The drug ordered might be eucalyptus, tincture of benzene (about
4 cc) or a few systoles of method to 600 cc of water Graduated
measure
Procedure
Inhaler should be warmed and glass mouth piece boiled measure the
drug as ordered. Either point in the graduate measure 900 cc of cold
water and 500 cc of boiled water to bring the temperate 82 0c or half by
half or pour half point (300cc) of boiling water into the inhaler than 5 co of
tincture of benzene or any other drug ordered. Then add another 300 cc
water making sure that the temperature of water in the inhaler comes to
820C. This is done in order to have a good mixture of the drug. The level
of the fluid should not be above the spout.
Fix the mouthpiece firmly in the inhaler in direction opposite to the air
inlet and cover the inhaler with blanket or towel. Close windows.
Prepare the patient usually in a sitting - up position making sure that he

is well supported. Then put inhaler on a saucepan on the tray. Place the
tray on the over- bed table or on his knees in such a way that he can
bend over the inhaler easily.
Put the spout for the escape of steam away from him. Cover his head
with blanket. Tell the patient to breath in by putting his lip to the mouth
piece which may be protected by a piece of gauze, and breath out by
removing his lips for a moment from the mouth piece.
The treatment can take from 5-10 minutes after which the patient should
be kept warm and comfortable for some time.
N.B :
1. If a Nelson's inhaler is not available a wide- mouthed jug may used.
The patient should be covered up to the waist with a balance from a
canopy, or the mouth of the jug may be covered with a towel to make
the opening small enough for the patient to put his nose and mouth
(not eyes) on it.
2. For irrational, helpless patients, stay with them throughout the

procedure.
3. Report the amount and nature of any sputum or discharge.
Care of Equipment after use

• Pour out the water from the inhaler (not onto a sink)
• Wash the inhaler with hot water
• Boil the mouth piece
Emergency tray and Trolley

List of Emergency Drugs. List of Emergency Equipment
• O2 - Tourniquet
• Morphine sulfate - O2 mask or nasal

catheter
• Aramine - plaster
• Adrenalin( Epinephrin.) - Dressing scissors
• Levophed -Arm Board
• Phanergan - Small makintosh
'' towel''
• Aminophylline - Tongue depressor
• Allerour - Mouth gag
• Nor adrenaline - Air way
• Carmine (Nikethamide) - suction machine
• Lasix - Files
• Syringes and needles - Container with alcohol
• Digoxin - Receiver
• Na HCO3 (Sodium bicarbonate) - Bandage
• Swabs - Levin's tube
• Vitamin k - Ned blacks
• .9 Normal Saline
• 5% D/w with complete et
• Largatil
• Ergometrine
• Kcl (potassium chloride)
• 40% dextrose
Study Questions
1. Which one of the following rout of drug administration has fastest

action?
a. Oral c. Intravenous
b. Subcutaneous d. Rectal
2. Mention two indications for oral drug administration
3. State the 5 Rs during drug administration.
4. Which one of the following
of injection
site most preferred for
young children?
a. Vastus lateralis c. Deltoid muscle
b. Ventrogluteal d. Dorsogluteal
Explain the differenceeen
betw
intravenous injection and
intravenous infusion.
6. List at least three immediate complications of blood transfusion.
7. Define inhalation
5.
UNIT NINE
WOUND CARE
Learning Objectives
• Differentiate types of wounds.

• Explain the purpose of wound care.
• List important equipment needed to provide wound care.
• Perform dressing of clean and septic wounds.
• Provide care for the patient with draining wound.
• Demonstrate skill of wound suturing and irrigation.
• Apply clip and remove it when indicated.
1. Dressing of a Clean Wound
Purpose
• To keep wound clean
• To prevent the wound from injury and contamination
• To keep in position drugs applied locally
• To keep edges of the wound together by immobilization
• To apply pressure
Equipment
• Pick up forceps in a container
• Sterile bowl or kidney dish
• Sterile cotton balls
• Sterile galipot
• Sterile gauze
• Three sterile forceps
• Rubber sheet with its cover
• Antiseptic solution as ordered
138
• Adhesive tape or bandages
• Scissors
• Ointment or other types of drugs as needed
• Receiver
• Spatula if needed
• Benzene or ether.
Technique
Aseptic technique to prevent infection
Procedure
Explain procedure to the patient
• Clean trolley or tray; assemble sterile equipment on one side and
clean items on the other side. Make sure it is covered.
• Drape and put patient in comfortable position.

• Place rubber sheet and its cover under the affected side.
• Remove the outer layer of the dressing e.g. adhesive tape
bandage.
• Remove the inner layer of the dressing using the first sterile
forceps and discard both the soiled dressing and the forceps.
• Take the second sterile forceps. Clean wound with cotton balls
soaked in antiseptic solution, starting from inside to the outside.
• Again use the second forceps to clean the skin around and remove
adhesive with benzene or ether.
• Apply medication if any and dress the wound with sterile gauze.
Method of Application
• Ointment and paste must be smeared with spatula on gauze and
then applied on the wound.
• Solutions or powder can be applied direct on the wound.

• Make sure that the wound is properly covered.
• Fix dressing in place using adhesive tape or bandage.
• Leave patient comfortable and tidy
• Record state of wound
139
• Clean and return equipment to proper place
N.B.
The above-mentioned equipment can be prepared in a separate
pack if central sterilization department is available.
2. Dressing of Septic Wound
The purpose is to
• Absorb materials being discharge from the wound
• Apply pressure to the area
• Apply local medication
• Prevent pain, swelling and injury
Equipment
• Sterile galipot
• Sterile kidney dish
• Sterile gauze
• Sterile forceps 3
• Sterile test tube or slide
• Sterile cotton- tipped application
• Sterile pair of gloves, if needed, in case of gas gangrene rabies
etc.
• Rubber sheet and its cover
• Local medication if ordered
• Spatula
• Receiver with strong disinfect
ant to immerse used instrument
• Probe and director if required
• Scissors
• Benzene or ether
• Bandages or adhesive tape
• Bucket to put in soiled dressing
Procedure
140
• Clean trolley o tray and assemble sterile equipment on one side
and surgically clean items on the other side. Make sure the tray or
trolley is covered.
• Drape patient and position comfortably.

• Place rubber sheet and its cover under the affected part
• First remove the outer layer of the dressing
• Wear gloves if necessary. Use, forceps to remove the inner layer
of the dressing smoothly and discard there for caps.
• Observe wound and check if there is drainage rubber or tube.

• Take specimen for culture or slide if ordered (Do not cleanse
wound with antiseptic before you obtain the specimen.)
• Start cleaning wound from the cleanest part of the wound to the
most contaminated part using antiseptic solution.
• ( H2O2 3% is commonly used for septic wound). Discard cotton ball

used for cleaning after each stroke over the wound.
• Cleanse the skin around the wound to remove the plaster gum with
benzene or either
• Use cotton balls for drying the skin around properly

• Dress the wound and make sure that the wound is covered
completely
• Fix dressing in place with adhesive tape or bandages

• Cleanse and return equipment to its proper places and discard
• Soiled dressings properly to prevent cross infection in the ward.
N.B.
• If sterile forceps are not available, use sterile gloves
• Immerse used for cape. Scissors and other instrument in strong

antiseptic solution before cleansing and discard soiled dressing
properly.
141
• In a big ward it is best to give priorities to clean wounds and then
to septic wounds, when changing dressings, as this night lessen
the risk of cross infection.
• Consideration should be given to provide privacy for the patient

while dressing the wound.
• Wounds should not be too tightly packed in effort to absorb
discharge as this may delay healing.
4. Dressing with Drainage Tube
Purpose
• Aids to prevent haematoma or collection of fluid in the affected
area.
Equipment
• Sterile galipot
• Sterile Scissors
• 3 Sterile forceps
• Sterile gauze
• Anti Sterile solution as ordered
• Sterile safety pins if needed
• Cotton wool or absorbent
• Receiver
• Adhesive ape or bandage
• Plastic scissors
• Ointment paste or paraffin gauze
142
•
Spatulas if needed
• One pair sterile gloves if available.
Procedure
• Cleanse tray or trolley and organize the needed equipment and
make sure it is covered.
• Drape and position the patient according to the need and put
rubber sheet and its cover under the part to be dressed
• Remove the outer layer of the dressing

• Use sterile forceps and remove the inner layer of the dressing (pay
attaint so that the drainage tube is non pulled out with the old
dressing)
• Observe the wound for the type and amount of discharge

• Clean the wound with cotton balls soaked in antiseptic solution.
• Grasp the top of the drainage tube with sterile forceps. Pull it cup a
short distance while using gentle rotation and cut off the tip of the
drain with sterile scissors (the length to be cut, depends on the
instruction. order.
• Place sterile safety pin through the drainage tube close to the
wound using sterile gloves or sterile gauze, if it is in the abdomen
to stop the drainage tube slipping down out of sight.
• Make sure the wound and the skin around are properly cleaned.
• Apply ointment or paste to the skin with spatula directly around to
prevent irritation and excoriation (if the excoriation exists use
paraffin gauze to prevent further complications).
• Cut the gauze towards its center to fit around robber drainage.
Tube, so that it fits properly around the tube thus preventing
discomfort.
143
• Use adhesive tape or bandages to secure the dressing in place.
• Record state of wound and the drainage.
Note.
• Safe method should be used for disposing old dressing. Gauze
and cotton used for cleaning wound.
• Take preventive measures to avoid skin irritation and excoriation.

• If drainage tube is attached to the bottle precaution must be taken
to secure the tube in place and avoid the risk of Gross infection.
Wound Irrigation
Purpose
• To cleans and maintain. Free drainage of infected wounds.
Equipment
• Sterile galipot or kidney dish
• Sterile gauze
• 3 Sterile forceps
• Sterile catheter
• Sterile syringe 20 cc
• 2 receiver
• Solutions (H
2O2 or normal sullen are commonly used)
• Adhesive tape or bandage

• Bandage scissors
• Receiver for soiled dressings
Procedure
Explain the procedure to the patient and organize the needed items.
• Drape position patient
144
•
•
• Put rubber sheet and its cover under the part to be irrigated
• Remove the outer layer of the dressing
Remove the inner layer of the dressing using the first sterile
forceps.
Put the receiver under patient to receive the out flow

• Use syringe with desired amount of solution fitted with the
catheter.
• Use syringes with forceps to direct the catheter into the wound.
• First inject the solution such as H2O2 at body temperature gently
and wait for the flow. This must be followed by normal saline for
rinsing.
• Make sure the wound is cleaned and dried properly.

• Dress the wound and check if it is covered completely
• Secure dressing in place with adhesive tape or bandage
• Record the state of the wound
• Clean and return equipment to its proper place.
Note:
• Keep patient in a certain position. According to the need so that
solution will flow from wound down to the receiver.
• Use sterile technique and warn solution for irrigating the wound.
Suturing
Definition: The application of stitch on body tissues with the surgical

needle & thread.
Purpose
145
• To approximate wound edges until healing occurs
• To speed up healing of wound
• To minimize the chance of infection
• For esthetic purpose
Equipment
• Tray or trolley covered with a sterile towel
• Sterile needle holder
146
•
•
Sterile round needle (2)
• Sterile cutting needle (2) Sterile silk
• Sterile cat- gut

• Sterile tissue forceps
• Sterile suture scissors

• Sterile cotton swabs in a galipot
• Sterile solution for cleaning
• Sterile dressing forceps
• Sterile receiver
• Sterile gauze
• Sterile plaster
• Dressing scissors
• Local anesthesia
• Sterile needle & syringes
• Sterile gloves
• Sterile hole- towel (Fenestrated towel)
Procedure
• Adjust light
• Wash your hands
• Clean the wound thoroughly
• Wash your hands again
• Put on sterile gloves
• Drape the Wound with the hold- sheet
• Infiltrate the edges of the wound to be sutured with local
anesthesia.
147
•
•
• Approximate the edges of the fascia with the help of the tissue
forceps and using the round needle and cat- gut. Suture the fascia
layer first.
Using the cutting needle and silk, suture the outer layer of skin
approximating the edges with the help of the tissue forceps.
Clean with iodine and cover with sterile gauze.

• Remove the hole- Sheet
• Make patient comfortable
• Remove all equipment, wash & return to its proper place or send
for sterilization.
Note:
• Do not suture wounds that are over 12 hrs old. How ever, such
wounds have to be seen by a doctor since excision of all dead &
devitalized tissue and eventual suturing may be required.
• Check that the patient gets his order for T.A.T before he leaves the
hospital.
• Do not you puncture (deep) wound.

• Before you suture any wound, make sure it is free of any foreign
bodies.
Removal of the Stitch

Technique: Use aseptic technique
Principles
• Sutures may be removed all at a time or may be removed
alternatively.
148
•
•
• Do not cur stitches in more than one place as a part of it may be
left behind and may cause infection.
• Suture is lifted slightly by the knot to allow scissors to go under

and one part of the suturing from the cleanest part of the wound to
the most contaminated part.
• Cleanse the skin around with antiseptic. Remove – gum with

benzene or ether and discard the forceps
Place sterile gauze to receive pleases or sutures.

• Take a pair of scissors in the right hand.
Take a dissecting forceps in the left hand.
• Pull-up gently the knot resting against the skin with the forceps,
pass the point of the scissors under the do not then cut the stitch
149
•
•
on one side and remove.
• Receive pieces of stitches on a sterile gauze
• Inspect the scar for wound healing and apply iodine on the skin
punctures if patient is not sensitive to iodine.
• Apply dressing
• Keep patient comfortable and tide
• Record the state of the wound
• Clean and return equipment to their proper places.
Clips
Definition:
Metal suture used to stitch the skin
Purpose
Someas suturing with
stitch
Equipment
• Michel clip applier
• Tissue forceps (toothed dissecting forceps
• Cleaning material- same as stuttering with stitch.
Procedure
The first part of procedure is the same as for suturing
Except
with stitch
that instead of suturing the skin with thread and needle you would apply
clips with the applier.
Removal of Clips
Technique
Use aseptic technique
150
Equipment
• Sterile gauze
• Sterile forceps 3
• Sterile clip removal forceps
• Antiseptic solution (Savalon 1% and iodine)
• Receiver
• Benzene or ether
• Adhesive tape or bandage
Procedure
Explain procedure to the patient and organize the needed equipment
• Drape and position patient
• Protect bedding with rubber sheet and its cover
• Remove old dressing and discard.
• Cleans wound with antiseptic solution starting for he cleanest part of the
wound to the most contaminated part and discard the cotton ball.
• Place sterile gauze to receive removed clips.

• Take clip remove with the right hand and dissecting forceps with the
seft hand.
• Insert the lower blade of the clip remove below the middle of the clip
using the dissecting forceps as a support of old the clips in place, and
close the blade firmly as this will cause disagreement of the clips from
the skin.
• Receive clips on sterile gauze

• Apply iodine on the skin punctures if required
• Dress the area if required
• Secure dressing in place with adhesive tape
151
• Record the state of scare
• Clean and return used equipment to its proper place.
Study Questions
1. Identify different types of wound care.
2. Mention the purposesof septic wound dressing.

3. Describe suturing.
4. What is clip?
152
UNIT TEN
PRE & POSTOPERATIVE NURSING CARE
Learning objectives:
List steps in pre operative preparation.
Identify the high-risk surgical patients.
Describe the major assessment skills, needed in the pre operative,
intra operative, and postoperative stages.
Explain the purpose of informed consent.

Perform general postoperative measures such as: obtaining vital
sings, assessing level of consciousness, assessing surgical pain.
Report and document post operative complication.

Assess for patient air way.
Pre-operative
Purpose
• To prepare the patient emotionally, mentally and physically for
surgery.
• To prevent any complication before, during and after surgery.
Equipment
As necessary
• It is important that the patient be in a good state of physical health
before he has surgery. Unless it is an emergency operation.
• He should have balanced diet, fluid, sleep and rest before his
surgery.
• The patient’s mental state is important to his recovery. Try to

relieve his fears about the operation and any fear of death: explain
153
to him what will be done and that every measure will be taken for
his safety.
Procedure
The day before surgery:
• Give the patient a complete bed bath to keep the body clean
before surgery. Give special attention to the umbilicus and other
areas of the body. Keep the fingernails and the nails of the toe
short and clean.
• Be sure the patient’s hair is clean. If the surgery is on the face,

neck, shoulders or upper chest, the hair should be the roughly
washed, combed and tied up to keep it from touching the
operative area. If the surgery is on the head the area must be
shaved and the hair washed.
• If an enema has been ordered the night before surgery. Be sure

this is given and is effective. Chart the results.
• If the patient does not yet understand what will be done. Explain
briefly what the operation is and how it will help him. Avoid telling
him anything that would make him worry.
• It is important that the patient has a good sleep the night before
his operation. Make him comfortable and turn out the light in his
room early. If he is unable to sleep report to the doctor.
• Have patient or relative sign consent for the operation

• Instructs patient about deep breathing and enough exercise
Day of Surgery:
• If the surgery is in the morning be sure the patient is prepared
early. Any thing abnormal such as pain, fever cough rapid pulse or
elevated blood pressure must be reported immediately. The
surgery may have to be canceled or delayed until the patient is
well.
154
• If the surgery is in the morning, nothing should be taken by mouth
after midnight (N.P.O.) if the surgery is in the afternoon., fluids and
food should not be taken in the morning depending on the orders
• Check the cleanliness of body areas, umbilicus, nails and hair.

• Shave the hair from the skin of the operative area thoroughly.
Some one should check to see if all the hair has been removed.
Wash the skin well with soap and water before and after shaving.
• Cheek the orders for preoperative treatment, such as enema,
catheterization of folly catheter.
• The patient’s temperature, pulse, respiration’s and blood pressure

should be taken and recorded on the chart just before surgery.
• Give the premeditation as ordered, being careful to give the tight

amount at the right time to the right patient and record.
Just before surgery

• Just before it is time to take the patient void, if he is unable to void
inform the doctor.
• Have the patient Void, if he is unable to void inform the doctor.

• Assist patient to move to the stretcher. The patient may be very
sleepy or dizzy from the preoperative medications and may hurt
himself. Support the stretcher to keep it from rolling as the patient
moves onto it.
• Make sure his elbows are close to his sides or over his chest
prevent them from being pumped as the stretcher passes through
doorways.
• Reassure him as you take him to the operating room

• Make sure the chart is complete and take to the theater with the
patient.
155
Shaving
Purpose
To minimize the danger of infection by decreasing the number of
bacteria on the skin.
Equipment
Basin of warm water
Washcloth
Towel
Soap
Blade and razor holder, if available
Scissors
Rubber sheet and towel
Procedure
• Prepare the equipment and bring it to the bedside.
• Fold the top linen and cover the patient with the bath blanket ( if
available)
• Screen bed
• Make the patient comfortable in the best position for the procedure.
• Place the rubber sheet and towel under the part to protect the bed
linen.
• Wash the area well with soap and water.

• Leave the soap on the area while you have.
• When all the hair has been shaved off, rinse the skin with clear
water. (If hair is long it could be shortened before shaving)
• Wash it again with soap, and water. Use enough soap to make
lather.
• Be sure to wash all creases and folds very well.
156
• Rinse with clean water
• Repeat washing until the area is clean.
• Dry the skin well and examine it to see if bed linen.
• Make the patient comfortable and replace the bed linen.
Specific Area to be Shaved:
Head Operations
• Explain the reason for having the head to the patient
• If the hair is long, it must be cut short
• Wash the head and hair well
• Shave the area of the operation as directed. If it is a major
operation, the whole head should be shaved.
Eye Operation
• Cut the eyelashes as close as possible on both sides.
• Use some Vaseline on the blades of the scissors before you begin
to prevent the eyelashes from falling into the eye.
• They should stick to the Vaseline

• Shave the eyebrows on both sides if ordered only.
• Be very care full not injure the eye or let any hair fall into the eye.
Face Operation
• Shave the side of the face there the operation will be
• If the patient is a man, make sure that the face is completely free
from beard.
• Wash face
• Be careful not to get soap into the patient’s eyes.
Anterior Neck Operations:

• Wash the patient’s head and neck
157
• If the patient is a woman, tie her hair, and keep it away from her
neck, or cut it short.
• Shave the front and sides of the neck from the chin to the end of
the sternum, and out to the shoulders.
• The area must be clean.
Posterior Neck Operations:

• The head and neck should be washed. Cut the hair short or tie out
of the way.
• Shave at least 15cm. and around the place of incision.
Spinal-Operations
• Ask the doctor where the concession will be
• Shave at least 15-25cm. all around the area of incision.
Breast Operations
• Shave the anterior and posterior chest from neck to the waist line
on the side where the surgery will be
• Shave the axilla on that side and the arm as far down as the
elbow.
Kidney Operations
• Turn the patient on his side with the operative side upward.
• Shave from the sternum to the groin and across the side the same
width up to the spinal column.
• Shave the axilla on that operation is a long one, so a large area

must be prepared.
Abdominal operations
• Shave the whole abdomen from the end of the sternum down to
the pubes.
158
• The umbilicus must be clean
Perennial and Rectal Operations

• The pubic and perinea hair must be shaved from the pubes to the
anal area.
• Shave at least 15 cm. down the inside of the thighs both sides
Limb Operations
• The whole limb should be washed well
• Shaved at least 15 cm all around the operative area.
• If the operation is on the upper arm or the upper leg. The axilla or
perineum should be shaved as well.
• If the operation is near the hand or foot cut the nails very short and
clean them well.
Post- operative Care
Purpose
• To prevent any complication from anesthesia • To detect
any sign of postoperative complications
• To rehabilitate the patient.
159
Equipment
• Anesthetic bed
• Oxygen
• Sphygmomanometer
• Stereoscope
• Suction machine (as needed)
• Extra rubber sheet (as needed)
• I.V stand
• Emergency drugs (to be ready in wards)
• Bed blocks (as needed) for shock
Procedure
• Prepare anesthetic bed (see section on bed making)
• Assist operating room nurse or health assistance in planning
patient in bed. An unconscious patient may be placed on either his
right or left side unless his right or left side unless specifically
o Orders.
• Check postoperative orders.
• Take blood pressure, pulse and respiration as ordered (usually
every 15 minutes until stable)
• Encourage patient cough and breath deeply every 15 minutes for
two hours, and then every two hours until able to be up, unless
other orders are written.
• Check dressing for any excessive bleeding or drainage.

• Check for tubes to be connected to drainage bottle- no kinks in
tubing. Secure tubing bedding.
• If patient vomits, turn his head to the side to prevent aspiration and
checking.
• Observe patient closely for any signs of shock and hemorrhage.

• Report any untoward symptom immediately.
160
Charting
• Time of return
• General condition and appearance
⇐ State of consciousness
⇐ Color of skin
⇐ Temperature of skin to touch
⇐ Skin- moist or dry
⇐ Blood pressure, plus and respiration
⇐ Any unusual condition such as bleeding drainage, Vomiting
etc.
Generals Instructions
• If patient shows any signs of shock immediate action should be
taken and then be reported to the doctor. The head of the bed
should be lowered (If no gatches on bed, bed blocks may be used)
• Do not leave unconscious patient alone.

• Keep patient flat in bed with the head to the side (no pillows) and
avoid chilling.
• Watch color of skin, lips, and fingernails carefully,

• If there is any bleeding carry out the necessary measures and
report immediately.
• The patient is having pain after he is awake. Analgesics may be

given according to orders.
• Limit visitors in the patient’s room

• Carry out post-operative orders carefully]
• Carry out post-operative orders carefully
• Place patient in a comfortable position
Post-operative Care of Specific Surgeries
161
Brain Surgery
• Patient must lie on his back with out pillows unless ordered
otherwise.
• Room should be dark and quit to prevent irritation to the brain.
Breast Surgery
• Encourage deep breathing often, because of danger of pneumonia
• Special arm exercises should be given
Abdominal Surgery
• Encourage deep breathing
• Turn from side to side often
• Sit patient on edge of bed 1st day postoperatively and
• Start walking second day post operatively (unless contra-indicated)
• Intake and output should be recorded
• If gastric suction is present make sure it is working properly
• Frequent mouth care for patients who are not allowed to drink.
Eye Surgery
• Must lie very still because the incision and sutures can be
damaged by pulling on the eye muscles. Both eyes may be
covered.
• Room may be quiet and dark

• Patient must be fed.
Spinal Surgery
• Must lie on abdomen of back with bed flat, and supported by
fracture board mattress.
• Patient may be in a body cast. Care must be given to prevent bed

scares where the cast rubs.
162
Thyroidectomy
• Place in high lowers position. This will make it easier to breathe
since the pressure of dressing and swelling may give choking
feeling.
• An emergency tracheotomy set should always be at the bedside or

nurses office for first three days, in case of hemorrhage or swelling
trachea.
• The complication “ Thyroid crisis” must be reported immediately as

death can occur if condition is not treated quickly.
Tonsillectomy
Child
• Lie on abdomen or side to prevent blood drainage into throat,
lunge or stomach.
• Watch carefully for excessive bleeding.

Adult
• If conscious, he may sit in semi- fowler’s positron in order to spit
the blood more easily.
• Watch carefully for excessive bleeding.
Study Questions
1. Mention the purposes of preoperative nursing care.
2. Why shaving is indicated before surgery?
3. State purpose of postoperative nursing care.
4. List some important equipment to provide care for immediate
postoperative patients.
5. Why informed consent is required before surgery?
163
UNIT ELEVEN
POST MORTEM CARE
Learning Objectives
At completion of the unit the student will be able:
• Define death
• Identify sing of death.
• Confirm death in collaboration with.
• Reassure relatives of the dying patient.
• Provide care fore the dead body with respect ion.
• Transferee the dead body to morgue or his house.
A. Care of the Dying
Death:- Is the end of life and all the vital processes. Legal death
is the total absence of brain activities as assessed and
pronounced by the physician.
1. Death may come to all of us. We must try to make the patient
comfortable and free from pain till the end.
2. Tell the patient’s family about his serious condition.

3. If the dying patient is in a ward, move him to a room where there
are no other patients, if possible, if this is impossible, put screen
around his bed. Try not to disturb other patients.
4. Do not leave a dying patient alone. He may appear unconscious

but he may hear and understand all that is being said.
Care After Death
Definition: - This is the care given to the body after death. Also called
post-mortem care.
162
Purpose
1. To show respect for the dead
2. To prepare the body for burial
3. To prevent spread of infection
4. To show kindness to the family
Equipment
• Basin for water, wash cloth and towel
• Cotton
• Gauze
• Dressings and tape if necessary
• Clean sheet
• Stretcher
• Forceps
• Name tag
• Gloves, if necessary
Procedure
• Note the exact time of death and chart it
• If the doctor is present call him to pronounce death
• If the family membersnot
arepresent, send for them
• Wash hands and wear clean gloves according to agency policy
• Close doors to room or pull curtain
• Raise bed to comfortable working level (when necessary)
• Arrange for privacy and prevent other patients from seeing in to
room.
• Close patient's eyes and nose if necessary
• Remove N.G. tubes and other devices from patient's body
• Place patient in supine position
• Replace soiled dressing with clean ones when possible
• Bath patients as necessary
163
• Brush or comb hair
• Apply clean gown
• Care for valuable and personal belongings and document
dispersement
• Allow family to view patient and remain in room
• Attach special level if patient lad contagious disease
• Await arrival of ambulance or transfer to morgue
• Remove glares and wash hands
• Document the procedure
Study Questions
1. Define death.
2. How do you confirm the occurrence of death?
3. What are the purposes of post mortem care?
164
GLOSSARY
Ambulatory Walking
Aspiration Inhalation of foodstuff, vomitus or saliva into the
lungs.
Axilla Armpit (under arm).
Autoclave Equipment that decontaminates materials by
exposing them to steam under pressure.
Apnea Absence or lack of breathing
Anoxia Lack of oxygen in the tissue.
Asphyxia A condition produced by prolonged lack of
oxygen
Asepsis Absolute freedom from all microorganisms

Antiseptic Harmless chemicals that can kill microorganisms or prevent
them from multiplying.
Aplastic anemia Anemia resulting from destruction of bone

marrow cells.
Aseptic technique Procedure used to prevent microorganisms from

reaching the operation site.
Bed cradles A wire or wooden frame placed over the patient's

body or feet to support the weight of the
bedclothes.
Blood pressure The force exerted by the heart to pump the blood around
the body
Bradycardia Abnormally slow heartbeat.

Bounding pulse Stronger than normal heartbeat.
Catheter A soft rubber tube which is used for passage of
165
Cast A material that supported an injured part of the
body and makes it immobilize.
Clips Metallic materials that keep the skin together.
Congestion fluid.
Hyperemia, accumulation of blood in a part of
Contaminated Area that
blood contains
or fluid germs
in a part or disease-producing
of the body e.g., lung.
material.
Decontamination The process of rendering an item free from
Cyanosis Bluish color of lips, tip of the nose, and ear lobes
infection.
due to lack of or shortage of oxygen in the blood.
Defecation Act of excreting feces from the rectum.
Detergent A substance usually dissolved in water used as an aid for
cleaning purposes.
Diagnosis The decision regarding the nature of an illness, arrived at by

clinical assessment of the patient and result of
investigation.
Diastole The resting phase of the heart during which it fills with blood.
Digitalis A drug given to slow and strengthen the

heartbeat.
Disinfectant A chemical used to kill microorganisms.
Dry heat Air heated to high temperature by electricity and
used for sterilizing purposes.
Dyspnea Difficulty in breathing.
Edema Swelling due to water accumulation in body cells Enema
An injection of fluid into the colon or rectum.
Exhalation Breathing out.

Fahrenheit System of measuring heat
Fever Body temperature elevation above 370C
Flatus Gas in the intestines.
Foot board A board placed at the foot of the bed to support
the feet
Gastrostomy Making an artificial opening into the stomach
166
through which the patient is fed by pouring
nourishment through a tube directly into the
stomach.
Hypertension High blood pressure.

Hypo tension Low blood pressure.
Incontinence Loss of bladder or bowel control.
Infection Invasion of the body by germs.
Inflammation Reaction of the body to infection or injury, characterized by
redness, heat, pain, and swelling at the site.
Inhalation Breathing in.

Intake Fluid taken into the body.
Irrigation Injecting fluid into a cavity without interrupting its
return.
Isolation The act of setting apart. An isolation room or ward is one kept
for contagious or infectious diseases.
Microorganism Bacteria, virus, fungi, and spores.

Mitered corner A triangular fold made in bedclothes to hold them in place
at the corners.
Necrosis Death of tissue.

Nits The eggs of a louse.
Output All fluid lost from the body.
Orthopnea A condition in which one breathes easier in a
sitting position
Pediculosis Human louse infestation
Postural drainage Position adapted to facilitate expectoration of
material in patients with lung disease.
Postoperative After an operation.
Preoperative Before an operation
Pulse The beat of the heart felt in the arteries.
Pulse deficit The difference between apical pulse and radial
pulse.
167
Respiration Breathing rate.
Retention enema An injection of fluid that is retained in the rectum
for absorption into the blood stream.
Restraints Devices that limit the patient's ability to move in

order to protect him/her from injury.
Septic wound Infection wound; a wound containing infective

microorganisms.
Sitzbath A warm soaking of the rectum and perineal area.
Splint A device for immobilizing part of the body
Spore The seeds of microorganisms, which are
resistant to drying, heat, and disinfectants
Sterile Specially treated so that all microorganisms are

destroyed
Stethoscope Instrument for magnifying sound

Specimen A small amount of body excretion or body fluid
that is sent to a laboratory for examination.
Sphygmomanometer Blood pressure apparatus.
Suppository Rectally administered cones containing a
medication in the base that is soluble at body
temperature.
Sutures Materials that keep broken skin together.

Systole Blood pressure period during the beating phase of the heartbeat
during which blood is expelled from heat.
Sepsis Presence of microorganisms.

Temperature Degree of heat.
Tachycardia Abnormally fast heartbeat.
Thermometer An instrument used to measure temperature.
Transfusion Injection of blood into a vein.
Unconscious Not aware of or responding to surroundings.
Vital signs Signs of life (e.g., temperature, pulse rate, respiration
rate, blood pressure).
REFERENCES
Evelyn Pearce, A General Text Book of Nursing, 20th edition, 1989.

Aypee Brothers comp., New Delhi, India.
168
Grace Cole, Fundamentals of Nursing , Concepts and Skills, second
edition, 1996. Mosby Comp. Boston.
Hosley, Jones & Molle-Mathhews. Text Book for Medical Assistants,

1995. Lippncott Comp. Philadelphia.
Koizer. Erb. Fundamentals of Nursing. Concepts, process and practice,

fifth edition 1995.
Benjamin/Cummings Publishing Comp. Philadelphia.
Lynda Juall Carpento. Nursing Care Plan and Documentation, second

edition, 1995. J.B. Lippincott Comp. Philadelphia.
Margaret Clarke. Practical Nursing, 13th edition, 1983. Bailler Tindall,

London
Mary E. Scholes. Hand Book of Nursing Procedures, 1986. Blackwell

Scientific Publications, London.
Robyn Rice. Manual of Home Health Nursing Procedures, 1995.

Mosby Comp. Boston.
Sorensen and Luck Mann's. Basic Nursing, A psycho physiological

approach, 3rd edition, 1994. W.B. Saunders comp. Philadelphia.
Swearingen & Howard, Photo Atlas of Nursing Procedures, 3rd

edition, 1996. Benjamin Comp. California.
W. Kereta a patient care procedure manual for mid level health

workers. 1998 Ethiopia.
169
170

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LECTURE NOTES

For Nursing Students

Basic Nursing Arts

Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.

Important Guidelines for Printing and Photocopying

©2006 by Abraham Alano

Nursing is core part in health service delivery system in which health

My deepest appreciation is to Carter Center and Professor Dennis

I also extend many thanks to colleagues

ABBREVATIONS & SYMBOLS

A.C. Before meal (ante cibum)

Historical Background of Nursing

As human needs expanded, nursing development broadened; its interest

History of Nursing in Ethiopia

After the overthrown of the Dergue, the transitional government of

CARE OF THE PATIENT UNIT AND EQUIPMENT

General Instructions for All Nursing Procedures

4. Do not expose the patient unnecessarily.

6. Assemble necessary equipment before starting the procedure.

8. Record the procedure at the end.

A. Care of Patient Unit

I. THE PATIENT UNIT

A. Patient Care Unit: is the space where the patient is

The patient unit is of three types:

2. Semi private room – is a patient unit which can

⇒ Most commonly found in Ethiopia hospitals

• It should be attached to both sides of the bed

D. Bed Side Stand

• Used to store the utensils needed for clients care. Includes

• Has a towel rack on either sides or along the back

E. Over Bed Table

• Along side or over the bed or over a chair

• A movable lamp may also be used

• Useful for the client for reading or doing close work

• Important for the nurse during assessment

H. Suction and Oxygen Outlets

• Suction is a vacuum created in a tube that is used to pull

• Oxygen is one of the gases frequently used for health care

• Almost always available in the was at the head of the bed

• The blood pressure assess

• Used for client’sto maintainconstantcontactwithcare

II. Care of Patient Unit

• Dusting should be done from top to bottom i.e. from upward to

• While dusting, wounds or dressing should not be opened by other

B. Care of Hospital and Health Care Unite Equipments

1. General Instructions for Care of Hospital Equipment

• Protect mattresses with rubber sheets

• Do not sterilize rubber goods and glass articles together -

• Report promptly any damaged or missing equipment

2. Care of Equipment in General

• Wash well in hot soapy water. Use an abrasive, such as a

3. Care of Linen and Removal of Stains

• Torn linen should be mended or sent to the sewing room

• Iodine stained linen- apply ammonia, rinse and then wash

• Tea or coffee stains – wash in cold water and then pour

4. Care of Pick Up Forceps and Jars

Sterile equipment: material, which is free of all forms of

• Wash pick up forceps and jars and sterilize daily

Admission and Discharge

Describe different types of bed making

Mention purposes of bed making