Introduction

❖ Word Nursing is derived from the Latin word “Nutritious” meaning to “Nourish”.
➢ Nursing Symbol: - Lamp
➢ First researcher in Nursing: - Florence Nightingale
➢ About Florence Nightingale: -

• Born: - 12 May 1820

• Death: - 13 August 1910
• Place: - Florence (Italy)

➢ The founder of modern Nursing.

➢ Pioneer of modern Nursing.
➢ Lady with Lamp.
➢ International Nurses Day celebrated on 12 May.

VIRGINIA AVENEL HENDERSON

• Born in Kansas City Missouri.

• She is known as “Architect of Nursing and mother of us all.
• Born 30 Nov. 1897
• Death 19 March 1996
“First lady of Nursing”
➢ Twentieth century Florence Nightingale.
➢ Nightingale of Modern Nursing.
➢ The definition of nursing posted by Virginia Henderson (1966) was adopted by ICN in
1973.
- Nursing is an art, science and vocation.
➢ Core of Nursing: -
1. Promotion of health.
2. Prevention of illness.
3. Restoration of health.
4. Alleviation of suffering.

➢ Essential of Nursing: -
1. The science of Nursing.
2. The art of Nursing.
3. The spirit of Nursing.

➢ Scope of Nursing (Extent of Nursing) :-

• The individual
• The family
• The society

➢ Principles of Nursing: -
1. Safety: -
It means prevention of mechanical thermal, chemical and bacterial and
bacteriological injuries of the client & the workers and protection from all
problems.
2. Theraputic effectiveness
3. Comfort
4. Use of Resources.
5. Good workmanship
6. Individuality.

➢ Nursing – A Profession
It is an occupation with ethical components that is devoted to the promotion of
human and social welfare.

➢ A Professional Nurse:-
Professional nurse is a graduate of a recognized nursing school. Who has met the
requirement for a registered nurse in a state in which she is licensed to practice?

➢ Professional Nursing Role –

1). Caregiver
2). Advocate
3). Critical thinker
4). Teacher
5). Common cater
 6). Manager
7). Researcher
8). Rehabilitator

The literal meaning of word “NURSE”

N - Nobility, Knowledge

U - Usefulness, Understanding

R - Righteousness, Responsibilities

S - Simplicity, Sympathy

E - Efficiency, Equanimity.

➢ Ethical Aspect of the Nursing: -

- Ethics are the rules or principles that “Govern Right Conduct”
- Ethics word comes from Greek word ‘Ethos’ which means – Custom or
Guidingbelief.
- Ethics are characteristics of a profession are called Code.
- ICN Code of Ethics for Nurses (1973), Which are also known as core of Nursing.

➢ Some Important Points: -

1). Faye Glenn Abdullah (1960) - Twenty-one Nursing problem.
2). Dorothea E. Orem (1971) - Nursing Concepts of Practices (Self care deficit
theory)
3). Sister Callista Roy (1976) - An adaptation Model (Roy Adaptation Model)
4). Betty Neumann (1972) - Neumann system Model.

VITAL SIGNS (CARDINAL SIGN)

Vital sign reflects the body’s physiologic status and provide information critical to evaluate homeostatic
balance. It is a clinical measurement that indicate the state of patient essential body function.

They are called vital because they are governed (regulation and control) by vital organs, and deviation
show abnormal body function.

➢ Normal Vital Signs (Adult): -

1. Temperature – 98.60 F or 370 C
2. Pulse – 72/Minute (70 – 80 BPM)
3. Respiration – 16/Minutes (12 – 20 breath/Minute)
4. Blood pressure- 120/80 mm of Hg.
5. Pain – 5th vital sign

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1. TEMPERATURE: -
A degree of heat maintained by body or it is the balance between heat production & heat loss.
THERMOGENESIS -- Chemical regulation of heat production.
THERMOLYSIS -- Physical regulation of heat loss.
✓ Temperature / Heat regulation Centre – Hypothalamus.

A. THERMOGENESIS: -
a) Oxidation of food –
1 gm carbohydrate/protein gives - 4 Calorie
1 gm FAT 9 Calorie

b) Specific dynamic action of food-

Carbohydrate 50 – 60 %
Protein 30% (Maximum)
Fat 4%
Mixed Diet 12%

c) Exercise
d) Strong emotion
e) Hormonal effect – Increase adrenal /thyroid
f) Disease condition

B. THERMOLYSIS: -
i. SKIN—
a) Radiation (60%) -- Transfer of heat from surface of one object to
another which is are not in direct contact
b) Evaporation (22%) -- A process by which substance in liquid change
to vapor state.
c) Convection (15%) -- Heat transfer by air circulation.
d) Conduction (3%) -- Heat transfer from hot part to cold part.
ii. LUNG
iii. KIDNEY
iv. BOWELS

➢ Types of Temperature: -
1. CORE TEMPERATURE- Temperature of deep tissue of body. It remains constant.
2. SURFACE TEMPERATURE- Temperature of skin, subcutaneous tissue. It rise
and fall in relation to environment.
➢ KEY POINTS: -

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 • Normal Variation – 97 to 990 F (36.10C – 37.20C)
• Circadian rhythm/ Diurnal variation – Body Temperature normally changes 0.5 – 10C
during 24-hour period.
• Common site of Temperature-
o Axilla -- 97.60F = 36.40C
o Oral -- 98.60F =370C
o Rectal -- 99.60F = 37.50C
• Highest Temperature 4 -6 PM in evening
• Lowest Temperature 4 -6 AM in Morning
• After menstruation temperature decrease and after Ovulation temperature increase (0.5 -
10F) due to hormone progesterone.
• Use Dorsal surface of your hand while taking temperature
• Most reliable method of temperature assessment – RECTUM.
• Most common method of temperature assessment – ORAL.

➢ ASSESSMENT OF TEMPERATURE: -
a) Glass thermometer: -
Mercury: -
i. Highly heat sensitive
ii. Uniform expansion
iii. Economical & easily visible.

• There is a constriction above the bulb which prevent mercury fall.

• Before taking temperature clean thermometer from bulb to stem & after stem
to bulb (Less contaminated area to more contaminated area.)

Cleaning Before - Bulb to Stem.

After - Stem to Bulb.

➢ Disinfection of thermometer: -
No. Disinfection Strength Time
1. Dettol/ Fair enol 1:40 5 Minute
2. Savlon 1:20 5 Minute
3. Lysol 1:40 3 Minute

➢ Convert Formulas: -
a. 0C = (F-32) × 5/9
b. 0F = (C×9/5) + 32

b) Electronic:
- It contains battery power control unit and temperature sensitive
probe.Non-breakable and short time of reading.
Ideal for children.

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 c) Tympanic membrane thermometer: -
It contains sensor probe which is place into ear canal to detect infrared
radiation. Used for infant and younger child. Reading in 2 second.

d) Disposal paper thermometer: - It is single use paper thermometer. It consists sensor that
contain organic chemical dots which melt & change color at different Temperature.
Use Rectal / Oral / Axillary, Reading in less than 3 Minutes.
Example - Tempa Dot.

e) Temperature Sensitive or Strips: -

It is a strip consist heat sensitive indicators, can be use over forehead
& Abdomen.

F) Temperature Artery Thermometer: -

Used in infant and children.

➢ Common Site of Temperature Assessment: -

• Oral
• Axilla
• Rectum
• Groin
• Vagina

i. Oral Temperature: -
Place thermometer 2 minute. If person drink hot & cold drink,
smoking chew gum than wait for 15 minutes.
➢ Contraindication: -
• Unconscious
• Seizures
• Epilepsy
• Oral injury
• Cough
• Children under 6 years of age.
ii. Axillary temperature: -
Place thermometer for 5 minutes, ideal for new born & children.
iii. Rectum temperature: -
Place thermometer for 5 minutes.
Thermometer inserts - Adult - 1.5-inch
Children – 1 inch
➢ Contraindication: -
• Diarrhea
• Dysentery
• Rectal surgery
• Cancer rectum
 ❖ PYREXIA (FEVER)
• The raise in body Temperature above 990 F (37.20C).
• A cell can function efficiently between 34 – 410C {94 – 1060 F}.
i. Low Pyrexia = 99 – 1000 F
ii. Moderate Pyrexia =100 – 1030 F
iii. High Pyrexia = 1030 – 1050 F
iv. Hyper Pyrexia = Above 1050 F
v. Hyperthermia = ≥ 1050 F
vi. Normothermia/Euthermia = 98.60 F
vii. Hypothermia = Less than 950 F
viii. Sub normal Temperature = 95 – 980 F

➢ Type of Pyrexia: -

A. Onset/Invasion: - It is a period when body temperature rising (sudden/gradual.)

B. Fastigium/Stadium: - A period when body temperature reaches maximum level & remain
fairly constant at high temperature.

C.Defervescence/Decline: - The elevated temp. return to normal.

1030F fastigium

Onset Decline

990F

➢ Types: -
a) Crisis: - Sudden return to normal.
İ. True Crisis: - Temperature falls withy improvement in pt. condition
İİ. False Crisis: - Temperature fall but patient condition does not improve.
b) Lysis: - Temperature falls in zigzag manner for 2-3 day or week before reaching
normal & other symptoms also disappear.

Crisis Lysis
Thermometer
D. Constant /Continuous Fever: - The Temperature varies not more than 20 C b/w morning &
evening & not reach normal for a period of week.

E. Remittent fever: - The Temperature variation more than 20C b/w evening & morning and
doesn’t reach normal.

F. Intermittent Fever :- The temperature rise from normal to subnormal to high fever & back at
regular interval. The interval may vary from hours to 3 day. Eg.. Malaria, Kalaazar.

a. Tertian Fever :- The fever occur once in every 3rd day. 48-hour periodicity.
b. Qurtan Fever :- The fever occur in once every 4th day. Periodicity 72 hrs.
İ. Inverse fever: - The highest range of temperature in the morning & lowest in the
evening.

İİ. Hectic or swinging fever :- When the different between high & low point is very great
called hectic or swinging fever.
İİİ. Relapsing fever :- In which there are brief (fever) period followed by 1 – 2 day normal
temperature.
İV. Irregular fever :- When the fever is entirely irregular it can’t be classified in any group
of fever.
V. Rigor :- The sudden severe attack of shivering in which the body temperature rises
rapidly. Eg. Malaria.

➢ Stage of Rigor :-
• Cold = C
• Hot =H
• Sweat = S
Vİ. PUO: - (Pyrexia of Unknown Origin)
Illness at least 3 weak durations with fever more than 380C and
diagnosisnot established after 1 week hospital investigation.

2. PULSE: - The alternate expansion (rise) & recoil (fall) of an artery as the wave of blood is passed
through it during left ventricular contraction.

➢ Commonest Site: -
i. Temporal artery – Over the temporal bone.
ii. Carotid artery – side of neck. Used during cardiac arrest/shock in adult.
iii. Brachial artery – Above elbow in antecubital fossa. Used to measure
Blood Pressure and during cardiac arrest in infant.
iv. Radial artery – Thumb side of forearm at wrist. Common site for pulse
assessment.
v. Femoral artery – Groin area. Used to determine circulation in leg.
vi. Popliteal artery – Back of the knee in popliteal fossa. Used to determine
circulation in lower leg.
vii. Posterior tibial artery – Behind/ below medical malleolus. Used to
determine circulation to the foot.
 viii. Dorsalis pedis – Along top of foot. Used to determine circulation to the
foot
ix. Apical pulse – Over the apex of heart. Point of maximum Impulse.
Routinely used for Infant and children up to 3 years.

➢ Characteristic of Pulse :-
A. Rate: - Beats/minute
Before birth = 140 (120 -160)
At birth = 130 – 150
Infant = 120 (115 - 130)
Adult = 70 - 80 (60 – 100)
Old = 60 – 70

B. Rhythm: - The regularity of the beat.

• Dysrhythmias: - The variation or irregularity of the rhythm.
• Intermittent pulse: - The beat is missed at regular interval.
• Sinus arrhythmias: - The condition in which the pulse rate is rapid inspiration & slow
expiration.

• Dicrotic pulse:- One heart beat & two arterial pulsation giving sensation of double beat.
• Pulse deficit:- Difference between apical pulse and radial pulse.

C. Volume:- Fullness of artery.

a) Water hammer/ Corrigan’s/ collapsing pulse: The full volume pulse rapidly
collapsing E.g. Aortic regurgitation.
b) Bounding pulse: - The full blood volume pulse. Stroke volume
c) Pulsus alternan: - The rhythm is regular but volume has an alternative strong &
weak character. Ex. Heart block, Lt. V. failure.
d) Bigeminal pulse :- The irregular rhythm in which every other beat comes early.
Ex. MI.

e) Thready/ weak/ wiry pulse :- The small weak pulse that feels like wire or
thread. Ex. Shock, Diarrhea, Vomiting.
f) Paradoxical pulse :- The pulse feel weaker at inspiration Ex. Heart failure,
Cardiac damage.

D. Tension: - The degree of compressibility.

•High tension - difficult to compress.

•Low tension - Easy to compress.
❖ Method: -
• Palpation: - Tip finger 1st & 2nd. Never use thumb because there is an artery.
• Auscultation: - For apical pulse – stethoscope.
Position :- In Adult at 5th left intercostal space over midclavicular line (Mitral area).

In infant at 4th left intercostal space lateral to midclavicular line.

• If regular pulse = 30 sec × 2

• If irregular pulse = full one minute pulse.

3. RESPIRATION: -

Two types

• External Respiration: - The exchange of gases between lungs & blood.

• Internal Respiration: - The exchange of gases between blood & Tissue.

HUMAN RESPIRATORY ORGANS

➢ Characteristic of the respiration :-
• The number of respirations in one minute.
• Birth – 35 (30 -60/min.)
• Infant – 30 (20 – 40 /min.)
• Adult – 16 (12 – 20/min.)
• Old age – 10 – 24/min.
➢ Respiratory center present in medulla oblongata: -
1. Dyspnea: - The difficult, labored, pain full breathing.
2. Hyperventilation: - Over expansion of lungs by rapid & deep breathing.
3. Hypoventilation: - Under expansion of lung characterized by shallow breathing.
4. Hyperapnoea:- Deep breathing.
5. Eupnoea:- Normal breathing.
6. Tachypnoea:- Respiration more than 24 respiration/min.
7. Bradypnoea:- Respiration less than 10 respiration/min.
8. Hypoxia :- the lack of oxygen in tissue.
9. Hypoxaemia:- Lack of oxygen in blood.
10. Cyanosis:- The bluish skin discoloration due to lack of oxygen in tissue.
11. Apnoea:- Complete cessation of respiration.
12. Cheyne stoke’s respiration:- The rhythmic waxing & waning of respiration, from very
deep to very shallow breathing & temporary apnoea.
13. Orthopnoea:- Ability to breath only in upright sitting position or standing position.
14. Asphyxia:- the state of suffocation.
15. Biot’s respiration:- Shallow 2 -3 respiration followed by irregular period of apnoea.
16. Kussmaul’s respiration:- Regular but increased rate and depth of respiration.
17. Sigh:- Deep inspiration followed by prolonged expiration.

➢ Abnormal sounds :-
i. Stridor :- The vibration, shrill, harsh sound due to upper airway obstruction. Ex.
Laryngitis.

ii. Wheezing:- High pitch, whistling sound. Lower airway obstruction. Ex. Asthma

iii. Rahl/ Rale: - The bubling sound/ Rating sound due to mucus in air passage. Ex
Penumonia.
• For each 10F (0.60C ) Temperature increase = 7 – 10 beats/minute (Pulse)
increases
• For each 10F (0.60C ) Temperature increase = 4 breath/minute respiration
increases
• For each 10F Temperature increase = 7% oxygen consumption increases
• For each 10C Temperature increase = 13% oxygen consumption increase

-
12
4. BLOOD PRESSURE :-

The pressure exerted by the blood against the wall of artery as it flow through them.

➢ Types of B.P. :-
1. Systolic B.P. :- The highest pressure against the wall of artery during ventricular systole. Normal
Systolic B.P 120 mm of Hg.
2. Diastolic B.P. :- The lowest pressure of the blood against the wall of vessels when the heart is
resting. (The pressure just before the contraction of left ventricle.) Normal Diastolic B.P. 80 mm
of Hg.
Normal B.P. -- 120/80 mm of Hg. Or 16/11 KPa
➢ Assessment of B.P. :-
• Avoid smoking before 30 minute.
• Rest for 5 minute.
• Apply cup above anticubital fossa 2.5 cm (1 inch.)
• The first heard sound “Korotkoff sound” denote systolic B.P.
• When the sound cease it show diastolic B.P.
• Cuff deflate rate 2 -3 mm of Hg/second.
• The B.P. in the leg :- Systolic pressure higher 20 -30 mm of Hg. Diastolic
pressure same as arm.
➢ Artery use in B.P. measurement :-
• Arm – Brachial artery
• Thigh – Popliteal artery
• Ankle joint – Posterior tibial artery

Pulse Pressure - Difference between Systolic blood pressure and Diastolic blood Pressure

Normal Pulse pressure = 40 mm of Hg.

B.P. Systolic pressure (mm of Hg.) Diastolic pressure (mm of

Hg.)
Normal BP 120 80
Pre hypertension 120 -139 80 -89
Hypertension stage 1st 140 -159 90 -99
Hypertension stage 2 nd >160 >100
Hypotension <90 <60
• Ratio of Systolic pressure, Diastolic pressure and Pulse pressure is 3:2:1

❖ Types of Hyper Tension :-

• Primary Hypertension :- Unknown cause.
• Secondary Hypertension :- Known Patholgy

-
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The size of bladder of B.P Cuff.

A. Width 40% of arm circumference.

B. Length 80 % of arm circumference.

Cuff Bladder width (cm) Bladder length (cm)

Newborn 3 6
Infant 5 15
Child 8 21
Adult 13 30
Adult thigh 20 42
❖ Abnormal reading :-
• Wide bladder – Low reading.
• Narrow bladder – High reading
• Loose – High reading
• Deflate quick – BP low
• The instrument use to measure B.P. is Sphygmomanometer.
❖ Types of Sphygmomanometers: -
1. Mercury
2. Aneroid
3. Digital
❖ MABP (Mean Arterial Blood Pressure)
(2 × 𝐷𝑃) + 𝑆𝑃
MABP = 3 OR Diastolic pressure + 1/3 Pulse pressure

Normal value – 93 mm of Hg

5. PAIN :-

• It is 5th vital sign.

• In children: - “Wong baker faces Pain rating scale.

6. OXYGEN SATURATION (SaO2): - It is a vital sign.

• The oxygen saturation value is the present of all hemoglobin binding sites that occupied by
oxygen.
• Normal oxygen saturation – 95 -100%
• Pulse Oximeter – A noninvasive device that estimate a client’s blood oxygen saturation (SaO2)
 ACID-BASE BALANCE
➢ Acid:-
• They contain hydrogen ion (H+)
• They are hydrogen ion (H+) donor
• PH less than 7
• Taste – sour
Eg. HCl (Hydrochloric acid)
➢ Base:-
• They contain Hydroxide ion (OH--)
• They are H+ receptor.
• Taste Bitter
E.g. NaOH (sodium hydroxide)

PH (Power of Hydrogen):- PH (Power of Hydrogen) Scale invented by Dr. Soren Sorensen (1909)
1
PH = log H + (Negative logarithm of H+ ion)

Acid Base

0 Acidity 7 Alkalinity 14

Acid/Base balance:
Acid-Base balance means the net rate at which acid & base produce is equal to
rate at which acid & base excreted from body.

Acid-Base balance: It is done by following mechanism.

1. Chemical regulation
2. Physiological regulation
3. Potassium exchange

1. Chemical regulation:-
It is an immediate regulation which correct acid base imbalance within
seconds. It is done by Buffers.
 Buffers: -
A substance or a group of substances that can absorb or release H+ ion to correctan
acid imbalance. Body fluids have four types of buffer system.
i. Carbonic acid & Bicarbonate
ii. Phosphate buffer
iii. Plasma Protein –Albumin
iv. Hemoglobin

A. Carbonic acid & Bicarbonate

Co2 + H2O H2CO3 H+ + HCO3-
(Carbonic acid) (Bicarbonate)
Condition:-
If acidosis H+ + HCO3- H2CO3
If alkalosis OH- + H2CO3 H2O + HCO3-

• Normally the system maintain PH 7.4 with a ration of 20 part HCO3 (Bicarbonate) to 1 part
H2CO3 (Carbonate acid)
HCO - : H CO
3 2 3

20 : 1

24 mEq/L : 1.2 mEq/L

• The Carbonic acid concentration is controlled by excretion of CO2 in lungs.

• The Bicarbonate Concentration is controlled by Kidney.
o The Kidney excrete 50 mEq per day of nonvolatile acids.
o The lungs excrete 13000 – 30000 mEq per day of volatile acid in the form
of carbonic acid as CO2

B. Phosphate buffer: -

If acidosis H+ + HPO 4-2 H2PO4- (Dihydrogen Phosphate)

If alkalosis OH- + H2PO3 H2O + HPO4-2 (Monohydrogen Phosphate)

C. Plasma Protein – (Albumin) –

It is a negative charge protein.
H

R C COO-

NH2
 D. Hemoglobin: -

The Co2 diffuses into RBC & form carbonic acid. The carbonic acid dissociated into H+ in &
Bicarbonate (HCO3-). The H+ in attached to the hemoglobin & bicarbonate available for exchange with
chloride ion (chloride shift/Hamburger phenomena). In Lungs reverse chloride shift take place.

CO2 Diffuse RBC Carbonic acid (H2CO3)

Dissociate

H+ + HCO3 CL-

Chloride shift

H+ + Hb

Lungs

H+ + HbO2

H+ + HCO3-

H2CO3

Exhale from lungs CO2 + H2O

-
 2. Physiological regulation: -
A. Respiratory Mechanism-Lungs: -
It takes few minutes to balance.
• In Acidosis – respiratory rate & depth INCREASED.
• In Alkalosis – respiratory rate & depth DECREASED.

B. Renal Mechanism – Kidney:-

It takes few hours to several days to balance.
• In Acidosis – H+ ion secreted into tubules & combined with buffer for
excretion in urine.
• In Alkalosis – the excess bicarbonate secreted into tubules & combined
with sodium & excreted in urine.

3. Potassium exchange :-
• In acidosis – the H+ ion enter into cell & K+ ion leave the cell result in
Hyperkalemia.
• In alkalosis - H+ ion leave into ECP & K+ ion enter into cell result in
Hypokalemia.
• Normal potassium level – 3.5 – 5 mEq/L

In acid base imbalance monitor potassium level closely.

Acid base Imbalance

Death ACIDOSIS Normal ALKALOSIS Death

0 6.8 7.35 7.45 7.8

14

Classification

Acid base Imbalance

Acidosis Alkalosis

Respiratory Metabolic Respiratory Metabolic

-
 1. Respiratory acidosis: - Increased in H+ ion caused by alveolar hypoventilation.
➢ Causes: - Any condition causes obstruction or any defect in normal function of lungs.
• Asthma, COPD
• Bronchiectasis, Bronchitis
• Atelectasis
• Pulmonary edema, Pulmonary emboli, Pneumonia
• Emphysema
• Brain trauma
• CNS Depressant – Sedatives, Narcotics, Anesthesia
• Hypoventilation.
➢ Clinical Manifestion :-
• Hypoventilation
• Hyperkalemia
• Drowsiness, disorientation, Dizziness, headache, Coma
• Seizure
• Ventricular fibrillation, Warm flush skin, Hypotension
➢ Management:-
• O2 therapy
• Semi-fowler’s position
• Suctioning
• Increase hydration
• Encourage deep breath and cough
• Antibiotic if infection
• Endotracheal tube/ Mechanical ventilation provided if respiratory distress

2. Respiratory Alkalosis: - Decrease in H+ ion caused by alveolar hyperventilation.

➢ Causes: - Any condition causes over stimulation of respiration.
• Hyperventilation, Hypoxia, Hysteria
• Over ventilation by mechanical ventilation
• Pain, psychological and emotional trauma
• Fever
➢ Clinical Manifestation: -
• Initially Hyper ventilation causes tachypnoea.
• Hypokalemia, Hypocalcaemia
• Lethargy, Confusion
• Tachycardia, Dysrhythmia
• Convulsion
• Tetany, Numbness, Tingling, Seizure
• Nausea, Vomiting, Epigastric Pain
➢ Management: -
• Encourage appropriate breathing pattern.
• Voluntary holding the breath.
• Rebreathing mast/ Co2 breathing with paper bag.
• Provide care for ventilator patient.
• Injection calcium gluconate for tetany.

3. Metabolic Acidosis: - Increased in H+ ion caused by abnormal metabolic process.

➢ Causes: -
• Diabetes mellitus / Diabetic ketoacidosis (DKA)
• Renal insufficiency
• High fat diet
• Insufficient metabolism of carbohydrate.
• Malnutrition, Starvation.
• Excessive ingestion of Acetylsalicylic acid (Aspirin.)
• Severe diarrhea.
➢ Clinical Manifestation:-
• Kussmaul’s respiration (Deep, rapid respiration)
• Hyperkalemia
• Drowsiness, Confusion, headache, Coma
• Dysrhythmia, Warm flush skin, Hypotension
• Nausea & vomiting, Diarrhea

Management—Treat underlined cause of acidosis.

4. Metabolic Alkalosis:-
➢ Causes:-
• Massive blood transfusion
• Excessive Vomiting/ GI suctioning / Anta acid use.
• Diuretic
• Hyperaldosteronism
• Injection / Infusion of excess soda bicarbonate.
➢ Clinical Manifestation: -
• Hypoventilation (Respiratory & depth decrease.)
• Hypokalemia, Hypocalcaemia
• Tremors, Tetany, Muscle’s cramp, Tingling sensation
• Seizure
• Drowsiness, dizziness, nervousness, Confusion
• Tachycardia, Dysrhythmia
➢ Management - Treat underlined cause of alkalosis.
➢ ABG Analysis (Arterial Blood Gas Analysis)
 Sample – Arterial blood from redial artery or femoral artery.

PH 7.35

PCO2 35 -45 mm of Hg.

PO2 80 – 100 mm of Hg.

HCO3 22 – 27 mEq/L

SaO2 95 – 100%

Allen’s Test:-

• To determine collateral circulation in the hand & adequacy of ulnar artery.

• If pinkness fails to return in 6 -7 second then radial artery should not be used.
o Respiratory Acidosis – PH ↓ PCO2 ↑
o Respiratory Alkalosis – PH ↑ PCO2 ↓
o Metabolic Acidosis – PH ↓HCO 3- ↑
o Metabolic Alkalosis – PH ↑ HCO 3- ↓

Respiratory function indicator PCO2

Metabolic function indicator PCO3-

Category Respiratory Acidosis – Metabolic Acidosis- Alkalosis

Alkalosis
Compensation PH within Normal range PH within Normal range
-
Partial Compensation HCO3 Abnormal PCO2 Abnormal
-
Un Compensation HCO3 Normal PCO2 Normal

-
 ENEMA
Enema also known as Clyster.

The introduction of any fluid or solution in to the large intestine through rectum for the various

purpose.

Classification:-

1. Evacuant enema
2. Retained enema
ENEMA

Evacuant enema Retained enema

Simple Evacuant Medicated Enema Cold or Ice enema

Stimulate Anesthetic Nutrient Emollient Sedative

Enema enema enema enema enema

Purgative Anthelminthic Carminative Astringent Oil

Enema enema enema enema enema

Purpose of enema: -
1. Simple evacuant enema: -
• To stimulate defecation, to treat constipation.
2. Oil enema: -
• To soften the hard fecal matter.
3. Astringent enema: -
• To relieve inflammation & prevent bleeding.

4. Cold & Ice enema: -

• To reduce the body temperature.
5. Anthelminthic enema: -
• To kill & destroy intestinal parasite.
6. Carminative enema (antispasmodic enema): -
• To relieve gaseous distention.
• To pass flatus (abdominal gas)
7. Stimulant enema: -
• To stimulate a person in shock & collapse.
8. Sedative enema: -

-
 • To administer sedative medication.
9. Purgative enema :-
• To induce Peristalsis movement.
10. Nutrient enema:-
• To give nutrient & fluid
11. Emollient enema: -
• To protect & soothe mucus membrane of intestine & to check diarrhea.
12. Anesthetic enema: -
• To induce anesthesia.
13. Barium enema: -
• To make diagnosis.

➢ Important Point :-
a) Size of rectal tube/ catheter: -
• Adult - 22 french
• School age children - 14 – 18 french
• Infant - 12 french
b) Tube insertion :-
• Adult = 3 – 4 inch (7.5 - 10 cm)
• Child = 2 – 3 inch (5 – 7.5 cm)
1
• Infant = 1 - 12 inch (2.5 – 3.75 cm)
c) Amount :-
i. Retained enema - 100 – 150 ml.
ii. Evacuant enema - In case of adult - 500 – 1000 ml.
In case of child - 250 – 500 ml.
In case of Infant - < 250 ml.

d) Position of enema :-
Left lateral position or Sims (Left lateral prone)
• In retained enema foot end should be raised.
• In evacuant enema flat.

e) Height:-
• In case of cleaning enema-height of the can should not be above 18 inch or 45
cm.
• In case of retained enema-height of the can should not be above 8 inch or 20 cm.

f) Temperature of fluid:-
• In case of retained enema - At body temperature.
• In case of evacuant enema - Adult - 105o – 110o F
Children - 100o F
• Use of water-soluble jelly to lubricate 2 – 4 inches.
• The solution of enema: -
i. Simple evacuant enema:-
• Soap jelly solution - 50 ml to 1 liter water.
• NS enema – 1 teaspoon to 500 ml water.
• Tap water 500 ml.

ii. Oil enema :-

• Severe Constipation.
• First bowel movement.
• To avoid straining of suture after surgery.
• Solution :-
• Olive oil
• Castor Oil and Olive Oil (1:2)
• Sweet Oil or gingerly oil
Amount - 115 – 175 ml
Temperature of Oil - 100oF

iii. Purgative enema :-

• Pure glycerin - 15 – 30 ml
• Glycerin + water - 1: 2
• MgSo4 - 60 – 120 ml with water
• 1 - 2 - 3 enema
30 ml 60 ml 90ml
MgSo4 Glycerin Water
• Glycerin and Castor Oil - 1: 1

iv. Anthelminthic enema :-

• Infusion of quassia – 15 mg to 600ml water
• Hypertonic Saline Solution - 60 ml NS in 600 ml water.

v. Carminative enema (Antispasmodic) :-

• Turpentine - 8 – 16 ml + 600 – 1200 ml soap solution
• Tr. Asafetida - 8 – 18 ml + 600 – 1200 ml soap solution.
• Milk + Molasses - 90 – 230 ml + 90 – 230 ml

Milk Molasses

vi. Astringent enema: - ( Reduce inflammation & bleeding )

• Tannic acid - 2 gm + 600 ml water
• Sliver Nitrate - 2 % with water
• Alum - 30 gm + 600 ml water

vii. Cold enema /Ice enema:-

• To treat hyperpyrexia and Heat stroke.
• Water temperature 80 – 90o F

-
viii. Stimulant enema :-
• In case of Collapse & shock & opium poisoning.
Black Coffee - 1 table spoon + 300 ml water
Brandy - 15 ml + 120 – 180 ml glucose saltire

ix. Emollient enema: -

Starch and opium – 1 – 2 ml opium + 120 – 180 ml starch mucilage or rice water.

x. Nutrient enema:-
• Normal saline
• Glucose saline 2 – 5 %
• Peptonized Milk - 120ml
• Amount 180 – 270 ml 4 hourly
• Temp. 100oF

xi. Anesthetic enema: -

Avertin - 150 – 300 mg/kg

xii. Sedative enema: -

• Potassium bromide
• Choral hydrate
• Paraldehyde

xiii. Barium enema: -

• Barium Sulphate Dose 2 – 3 pints

➢ Methods of enema: -
a. Enema can & tube method: - When large amount of fluid to be given.
E.g. – Soap jelly enema.
b. Funnel & Catheter method: - When small amount of fluid to be given.
E.g. – Oil enema

c. Glycerine syringe & catheter method: - Small Quantities (Purgative enema)

d. Drip method: - When fluid administered at the slow rate i.e., nutrient enema.

-
 DRUG ADMINISTRATION

➢ Introduction:-
Patient with impaired health condition a nurse requires variety of medication. A
nurse must have sufficient knowledge about drug administration.
➢ Routes of Drug Administration: -
1) Oral: -
The drug is place into oral cavity to be swallowed.
• It is the Commonest Route.
2) Sub lingual: -
The drug is placed under the tongue to dissolve it. E.g., Tablet –
Nitroglycerin (Anginal Pain)
3) Buccal: -
Solid drug is placed in the mouth against the wall of mucus membrane of
cheek for local & systemic affect.
4) Inhalation: -
The volatile drug inhale into lungs through nose or oral cavity for local
& systemic effect. E.g., ether, chloroform, Bronchodilator.
5) Inunction: - (Topical Application)
Application of drug into skin by Friction/ Rubbing.
e.g., Emollient, Ointment, Liniment, Antiseptic
6) Instillation: -
Putting liquid drug into body cavity. E.g., Eye, Ear, Enema etc.
7) Insertition :-
Putting a solid drug into body cavity e.g., Suppository into rectum &
vagina.
8) Insufflation: -
Application of the drug in the form of powder, vapors, air into wound or
cavity.
9) Implantation :-
Putting a solid drug into body tissue.
10) Parentral :-
Para + Enterore

Beside + Intestine

➢ Types of Injections Site

a) IM - Muscle
b) SC/Hypodermic - Subcutaneous tissue
c) ID - Dermis
d) IV - Vein
e) Intra Cardiac - Cardiac muscle
f) Intra osseous - Bone marrow
g) Intra articular - The Joints cavity
h) Intra Arterial - Artery
i) Intra Peritoneal - Peritoneal cavity
➢ Right of safe drug Administration
There are traditionally 5 Rights –
i. Right medicine vi. Right Documentation
ii. Right dose vii. Right to Education
iii. Right time viii. Right to Evaluation
iv. Right Route ix. Right Assessment
v. Right Client x. Right to Refuse

➢ Abbreviation Related to time: -

Abbreviation Meaning
i. ac - Before meal
ii. Pc - After meal
iii. am - Before noon
iv. pm - After noon
v. alt die - Alternate day
vi. om - Each morning
vii. on - Each night
viii. hs - At bed time
ix. hn - To night
x. cm - Tomorrow morning
xi. prn - When required (As needed)
xii. sos - If necessary, in emergency
xiii. stat - at once
xiv. od - Once a day (daily)
xv. bd (bid) - 2 time in a day (Twice)
xvi. tds (tid) - 3 times in a day (Thrice)
xvii. q id - 4 times in a day
xviii. q - every
xix. h - hour
xx. rep. - Repeat
xxi. qh - every hour
xxii. qod - every other day

➢ Abbreviation related to drug form:-

Abbreviation Meaning
i. aq. - Water
ii. aq. dist. - Dist. Water
iii. comp. - Compound
iv. dil - dilute
v. et. - and
vi. fl. - Fluid
vii. Empl - plaster
viii. ung - ointment
ix. Lin - Liniment
x. Lot - Lotion
 xi. Inf. - Infusion
xii. Inj. - Injection
xiii. Tab. - Tablet
xiv. Cap. - Capsule
xv. Ol - Oil
xvi. Sp - Spirit
xvii. Syr. - Syrup
xviii. gtt - drop
xix. tsp = t - teaspoon
xx. Tbsp = T - table spoon
xxi. Pulv - Powder
xxii. Liq - Liquid
xxiii. Mist - Mixture

➢ Abbreviation related to Routes: -

Abbreviation Routes
a) AD - Right ear
b) AS - Left ear
c) AU - Both ear
d) OD - Right eye
e) OS - Left eye
f) OU - Both eye
g) PR/R - Per rectum
h) Po/Per os - Per oral
i) Rx - Take Prescription

➢ Equivalent Volume Conversation :-

a) 1 ml = 15 minim =15 drop = 15 gtt = 1 CC
b) 4 – 5 ml (5 ml) = 1 tsp =t = Teaspoon
c) 15 ml = 1 Tbsp = T = Tablespoon
d) 30 ml = 1 Fluid ounce (oz)
e) 500 ml = 1 pint
f) 1000 ml = 1 liter =1 quart = 10 deciliter = pint
g) 4 liters =1 Gallon
h) 1 Glassful = 200 ml = 8 ounce
i) 1 teacupful = 150 ml = 6 ounce
j) 1 ounce = 8 teaspoon

➢ Equivalent Weight Conversion:-

1
a) 1 mg = 60 grain
b) 60mg =1 grain
c) 1 gm =15 grain
d) 30 gm =1 ounce
e) 1 kg =1000 gm = 2.2 pound (Ibs)
f) 1 gm =1000 mg
 g) 1 mg =1000 mcg/ug
h) 4 gm =1dram

A. Young’s rule: - (1 – 12 year of child)

𝐴𝑔𝑒 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑 (𝑦𝑟.)
= 𝐴𝑔𝑒 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑 + 12 × Adult dose

B. Clark’s rule: - Weight for all children

𝑊𝑒𝑖𝑔ℎ𝑡 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑 (𝑃𝑜𝑢𝑛𝑑)
= 150 × Adult dose

C. Fried’s rule: - < 1 year

𝐴𝑔𝑒 𝑜𝑓 𝑐ℎ𝑖𝑙𝑑 (𝑚𝑜𝑛𝑡ℎ)
= 150 × Adult dose

Y F C
12 I W

D. Drop factor :- 𝑇𝑜𝑡𝑎𝑙 𝑣𝑜𝑙𝑢𝑚𝑒 (𝑀𝑙)

Flow rate or drop per minute = 𝑇𝑜𝑡𝑎𝑙 𝑡𝑖𝑚𝑒 (𝑀𝑖𝑛𝑢𝑡𝑒) × 𝐷𝑟𝑜𝑝 𝑓𝑎𝑐𝑡𝑜𝑟
• Macro drip set = DF = 15 drop (10 – 20 drop/m)
• Micro drip set = DF = 60 drop

e.g. 1000 ml NS 12 hour DF = 15

1000
= 12 × 60 × 15 = 20.8

= 21

E. Infusion time :-
𝑇𝑜𝑡𝑎𝑙 𝑉𝑜𝑙𝑢𝑚𝑒 (𝑚𝑙)
𝐼𝑛𝑓𝑢𝑠𝑖𝑜𝑛 𝑡𝑖𝑚𝑒 (ℎ𝑟) = 𝑚1
ℎ𝑟 𝑏𝑒𝑖𝑛𝑔 𝑖𝑛𝑓𝑢𝑠𝑒

𝑫
F. Dose Calculating formula :- =𝑨×𝑸
D = Desired dose (Prescribed)
A = Available dose (Dose in hand)
Q = Quantity (ml, tablet, capsule)

➢ Types of syringe :-
a) Disposable & Reusable
b) Luer Lok & Non Luer Lock
c) AD Syringle Auto disable syringe
d) Insulin syringe
Red = 40 unit.
Green = 80 unit.

-
 e) Tuberculin syringe = 0.01 ml minimum measure
3
length = 8 to 2 𝑜𝑟 10 ‒ 50 𝑚𝑚

Gauge = Bore – Internal diameter 14 – 30G

IM SC/Hypodermic ID IV
(1) Target Muscles Subcutaneous Dermis Vein

_
(2) Angle 90o thin/Average 45o 𝑐 10 – 15o (15) 15 – 45o (250
3 _
obese 90o
4" 𝐶
(3) Up to 5 ml mostly 3 < 1 ml 0.01 to 0.1 ml Amount
Amount ml depend upon
prescription
usually 2 –
10ml
(4) 2, 5 ml caliberation 1, 2, 3, ml 1 ml Size depend
Syringe 0.2 ml Cal. = 0.1 ml 0.01 ml upon amount
(2 – 10 ml)

(5) Needle G = 21, 22, 23 G = 25 G = 26, 27 G = 18 – 21

1 5 3 5
L = 1 – 2 inch L =2 ‒ 8 𝑖𝑛𝑐ℎ L = 8 ‒ 8𝑖𝑛𝑐ℎ L = 1 – 2
inch
-Gluteal (A) - Anterior -inner aspect -Vein of hand
Ventrogluteal (B) abdomen wall of forearm forearm &
Dorsogluteal -Outer aspect of -Upper aspect Antecubital
– Vastus lateralis upper arm of anterior & fossa
Sites -Deltoid 1 -2” below - Posterior chest Posterior
acromion process wall chest
- Anterior & -Posterior
lateral aspect of Aspect of
thigh upper arm

➢ IM Injection :-
• Most preferable site for IM injection is ventrogluteal in adult.
• Vastus lateralis – Most preferable site for IM injection in Infant.

➢ Z- Track Method:-
• This method uses to give irritating medicine (inj. iron, inj. vit-D) in muscles.
• It seals of the drug into muscles & prevent its leakage into subcutenous tissue.
• Do not massage after the injection.
• Clean the site in circular motion from center to outward (5 cm).
• If blood appear withdraw needle discard syringe & prepare a new injection.
• Inject 1 ml in 10 second.

-
➢ Sc Injection :-
Subcutaneous Injection.
e.g. – Insulin

• Low molecular weight Heparin.

• Measles

➢ I D Injection:-
• Tuberculin test (Left arm)
• Allergy.
• Drug sensitivity test.

➢ Key Points :-
i. Check 3 times for safe drug Administration.
ii. Hold multi dose bottle with label against palm of hard while pouring.
iii. Place medicine cup at eye level on a hard surface.

INJECTIONS SITES
 POSITION
1) Supine position/ Dorsal / Horizontal Recumbent :-
Patient lies flat on back with extremely extended & legs abducted.
➢ Purpose :-
• Comfort
• Vital signs
• Physical examination of anterior thorax, Hear, Abdomen.
• Surgery of anterior portion.
• Male Catherization

2) Dorsal Recumbent :-
Patient lies supine with knee flexed.
➢ Purpose :-

• Rectal & vaginal examination.

• Female catheterization.

3) Prone :-
_
Patient lies flat on abdomen 𝐶 head turn to one side.
➢ Purpose :-
• Examination, treatment, surgery of the back.
• Prevent pressure sore.
• To assess hip joint.
➢ Contraindication :-
• Respiration problem
• Spinal cord injury.
• Abdominal surgery.

4) Left lateral position (left side line ) :-

The patient lies on left side.
➢ Purpose :-
• Enema
• Rectal suppository
• Rectal examination
• Rectal temperature.

5) Sim’s (Left lateral prone ) :-

The Client lies on left side turn Prone 45o, lower leg extended, upper leg
flexed at knee 450 -90o.
➢ Purpose :-
• Rectal & vaginal examination.
• Enema.
6) Fowler’s position :-
Patient lies supine _
𝐶
Head of Bed elevated up to 45 – 60o (Typically – 45o)
i. High fowler’s position: -

Head of the bed elevated up to 900.

ii. Semi fowler’s position: -
Head of the bed elevated 450.

➢ Purpose:-
• To relive dyspnea
• In case of increase ICP
• Drainage from Abdominal Cavity.
• To Relieve tension of the abdominal suture
• To relax back & thigh muscles.

7) Cardiac / Orthopneic position:-

Patient in sitting position lean forward on over bed table.
➢ Purpose:-
• Severe dyspnea
• Cardiac problem

8) Trendelenburg position:- _
The patient lies supine 𝐶 Head 30 o – 40 o lower than feet.
➢ Purpose: -
• Pelvic examination or surgery.
• Shock & Hypotension.
• Postural drainage.
• To Promote venous return.
➢ Contraindication: -
İ. Increase ICP
İİ. Head & Spinal injury.

9) Reverse Trendelenburg position: -

the patient lie supine with head upper than feet.
➢ Purpose:-
• GERD
• Gastro esophageal reflux disease.

10) Lithotomy position: -

The client lies back (supine) hip & knee flexed at 900 & feet are in
stirrups.
➢ Purpose: -
• Gynecological examination & treatment.
• Genito urinary surgery.
• Normal delivery / Operative delivery.

-
 11) Knee chest / Genupectoral / Knee elbow :-
Patient lies prone on knee & chest.
➢ Purpose:-
• Sigmoidoscopy
• Rectal & Vaginal examination
• As a post partum exercise abdominal muscles relax a genic organ relax.

12) Rose position :-

_
Patient lies supine 𝐶 hyper extension of neck.
➢ Purpose:-
• During tonsillectomy.
• Adenoidectomy
• Uvuloplasty

13) Walcher’s position :-

_
Patient lies supine with Lower extremities leg fall over from the edge of mattress.
➢ Purpose:-
• Breech presentation
• Forceps delivery
• Relax Perineum

14) Jack Knife :-

Patient head & leg lower than hip.
➢ Purpose :-
• Surgery of Coccyx & Rectal.

15) Standing / Erect :-

Patient stands in erect posture.
➢ Purpose:-
• To assess posture balance & gait
• Orthopedic & Neurological examination.

16) Sitting Position:

➢ Purpose: -
• To assess the Vital signs.
• Physical examination of Head, neck, anterior & Posterior thorax.
➢ Key Points :-
i. Elevate –
Conditions: -
• Skin graft – immobilize.
• Amputation
• Burn
_
• Thrombophlebitis - C Rest
• Varicose vein – above heart level

-
 ii. Semifowler’s –
• Mastectomy
• Hypophysectomy
• Laryngectomy
• Bronchoscopy
• CVA (Cerebro Vascular Accident )
a) Hemorrhage - Semi fowler’s
b) Ischemic - Flat

iii. High fowler-

• NG Tube insertion
• Pulmonary edema
• Heart failure

iv. Semi fowler to fowler –

• 30o – 450 ICP

• Cerebral Aneurysm
• Craniotomy

v. Cardiac position :-

• COPD

➢ In Procedure :-

a) Kidney Biopsy –
• During – Prone
• After – Supine
b) Liver Biopsy –
• During – Supine
• After – Right lateral
c) Lumber Puncture –
• Side lying bowed back knees flexed chin toward the chest or C-shaped
position.
• After supine position for 4 -12 hour.
d) Paracentesis: -
_
• Semi fowler position or sitting upright C feet over table.
e) Thoracentesis-
• Sitting at the edge of the bad C_ feet over table.
_
• Side lying on unaffected side C head of bed elevated.
f) Air Embolism -
Left lateral Trendelenburg position.

g) Spinal cord injury –

 _
• Immobile on spinal back board C head neutral position (immobile)
• Logroll --- Do not turn or twist the patient.

h) Tonsillectomy –
• After -- Prone/ side lying position.

i) Myelogram –
• Contrast medium
• Oil soluble dye -- Flat
• Water soluble dye – elevated head 30 – 60o.

j) Central venous pressure (CVP) 3 – 8 mmHg Normal –

• Supine with head of bed at 45o
• Zero point should be at the level of Right Atrium (4th inter costal space at
mid-axillary line)

k) Hemorrhoidectomy –
• Side lying position

l) Appendectomy –
• Right lateral or semi fowler.
CPR (Cardio Pulmonary Resuscitation) or BLS (Basic Life Support)

Definition :- It is an emergency life saving procedure done when persons breathing & heart
stops. It provide O2 to vital organs until help arrives.
Indication
➢ Cardiac Arrest :-
• CO2/CO poisioning
• Drowing
• Airway obstruction
• Electric shock
• Drug reaction
• Heart failure
➢ Assessment :-
Cardinal Sign -- 1) Apnoea
2) Absence Carotid pulse
3) Dilated pupil
4) Unconscious, cyanosis, fits
Sequence of CPR for Health care provider :-
1. Determine unconsciousness
2. Assess pulse 5 to 10 second
3. Perform chest compression
4. Open airway
5. Check breathing & deliver breathing
CAB Formula :-
1. C - Compression
2. A - Airway
3. B - Breathing
4. D - Defibrillation or Definitive Treatment

1. Compression –
• Place the patient in supine over firm & flat surface.
• Push hard & fast.
• Allow complete recoil after compression.
 Adult > 8 yrs. Child 1 – 8 yrs. Infant < 1 yrs.
Pulse Assessment Carotid Femoral Brachial/ Femoral
5 -10 second
Compression Two hand One hand To finger or Two
Method thumb
Lower half of
sternum
1
Compression depth 2” 2” 12" (1.5)
Compression Rate 100/minute 100/minute 100/minute
(Approximately)
Compression Center of chest Center of chest Just below Nipple
Landmark between Nipple between Nipple line

2. Airway :-
• After performing 30 compressions opens victim’s Airway.
• Head tilt & chin lift method.
• If the person head, Neck, spinal cord injury then used jaw thrust maneuver.

3. Breathing :-
• Pinch the nostrils & give mouth to mouth breathing.
• Mouth to nose.
• Mouth to stoma breathing can also be given.
• If the person is not breathing then 2 affective breathing of 1 second/breath given.
_
• Each rescue breathing deliver over 1 second 𝑐 visible chest rise.
• Ventilation rate = 8 – 10 ventilation/ minute.
• Each breath should be delivered after every 6 -8 second.

Adult Child/Infant

Compression 30:2 30:2 – One Rescuer

Ventilation 1 or 2 15:2 – Two Rescuer

Activate Emergency medical system :-

• Phone first Adult 8 year

• Phone first Child/infant (After completion of 5 cycle of CPR at ration 30:2)
 4. Defibrillation –
• Provide therapeutic dose of electric energy to the patient.
• Call clear three time & check no one is a touching the bed.

Foreign body Airway Obstruction (FBAO)

a) Adult & child – Abdominal thrust maneuver/ Heimlich maneuver –
Stand behind the victim

Place arm around Patient’s waist

Make a fist B/w xiphoid process & umbilicus

Deliver 5 inward & upward thrust

b) Obese person or in advance Pregnancy - chest thrust –

Place arm under axilla & hands at the middle of chest.

Deliver 5 chest thrust

c) Infant – Back slap & chest thrust –
Procedure
_
Place the infant over arm C head lower than body withholding the jaw

Deliver 5 back slap between shoulder blade.

Turn the infant

Deliver 5 chest thrust (2 finger method)

 BIO MEDICAL WASTE
• Biomedical waste management & handling rule 1998.
• Came into force 28 July 1998.
• It is prescribed by ministry of environment & forest.

According to the biomedical waste management & Handling rule—

• Biomedical waster is any waster which is generation during diagnosis, treatment &
immunization of human being or Animals, in research activities, in the production or
testing the biological & including the category as mention is schedule 1 table 4.
Option Waste category Treatment/ Disposal
Category- 1 Human anatomical waste Incineration/ Deep burial
(tissue, organ, body parts)
Category- 2 Animal waste Incineration/ Deep burial
(Tissue, organ body parts)
Category- 3 Microbiology & Biotechnology waste Autocalve/ microwave/
agent, toxin, culture, specimen, incineration
vaccines
Category-4 Waste sharp Chemical treatment/ Auto
(Blade, Needle, syringe) clave/ microwave/
Shreeding/ mutilation
Physical distroid
Category- 5 Discarded medicine & cytotoxic drugs Incineration/ dispose in
secure land fill
Category- 6 Soiled waste Incineration / Autoclave/
_
Waste contamination 𝐶 blood cotton, microwave
dressing, plaster etc.
Category- 7 Solid waste disposable, rubber iv set, Chemical treatment/ Auto
catheter etc. Clave microwave/
shreeding/ mutilation
Category- 8 Liquid waste Chemical treatment then
Laboratory waste discharge into drainage
Category- 9 Incineration Ash Municipal secure land fill
Category- 10 Chemical used in production of Chemical treatment
biological & disinifection If solid -- Landfill
If liquid – Discharge into
drain

-
 Schedule – II
Colour Type of contain Category Treatment
(1) Yellow Plastic bag 1, 2, 3, 6 Incineration/ Deep
Human & Animal burial
anatomical waste ---
(Cell tissue,
Amputated part,
placenta, Plaster,
Bandage, Dressing,
Bedding, Cotton
mixed blood)
(2) Red Plastic bag 3, 6, 7 Chemical treatment
Disposable rubber autoclave/ microwave
items ---
I.V. Set, Cather, NG,
Tube, Used gloves,
Discarded blood bags,
Specimen container
culture.
(3) Blue/White Puncture proof 4, 7 Chemical treatment
container Sharp, Glassware, Autoclave/ microwave
Needles, Syringe, shredding
Scalpels (blade)
Ampoules, Vials,
Glass bottles
(4) Black Plastic bag 5, 9, 10 (solid) Secure Land fills
General waste from
patient & hospital,
Paper, Food discarded
medicine

• Category 8 & Catogry 10 (liquid) does not required any plastic bag.
• Incineration is the best method to dispose biomedical waste.
• Inertization- Biomedical waste mixed with cement or other substance to prevent.

-
 HOT & COLD APPLICATION
Primary effect: -
Hot
(1) Peripheral Vasodilation
(2) Increase Capillary permeability
(3) Increase Local metabolism
(4) Increase 02 Consumptions
(5) Increase Blood/Lymph flow
(6) Increase Motility of leucocyte
(7) Decrease Blood viscosity
(8)Duration – 20 – 40 minute
Cold
(1) Peripheral vasocontraction
(2)Decrease Capillary
permeability
(3) Decrease Local metabolism
(4)Decrease 02 Consumption
(5) Decrease Blood/lymph flow
(6)Decrease Motility of leucocyte
(7) Increase Blood viscosity
(8) Duration – 30 – 60 minute

Therapeutic effect :-
Hot Cold
(1) Decrease Pain (1) Decrease Pain (Nerve conduction slow)
(2) Decrease Muscle tone (2) Prevent gangrene
(3) Heat promote healing (3) To prevent edema & Decrease inflammation
(4) Heat promote suppuration (4) Check hemorrhage
(5) Soften the exudate (5) To check bacterial growth
(6) To provide warmth (6) To reduce body temperature
(7) Heat induce peristalsis (7) To anesthetize the area (loss of sensation)

Contra indication :-
Hot Cold
(1) Malignancy (1) Shock/ Collapse
(2) Acute inflammation (2) Diabetes mellitus
e.g., Appendicitis, tooth abscess
(3) Acute hemorrhage (3) Arteriosclerosis
(4) Open wound (4) Neuropathy
(5) Impaired kidney, heat, lung function (5) Shivering
(6) Edema (6) Decrease Body Temperature
(7) Edema
 d by- Dagur ji

Classification of hot Application

Local General

Dry Moist Dry Moist heat

1. Infrared 1. Stupes
2. UV lamp 2. Poultices 1. Sun bath 1. Steam bath
3. Heating lamp 3. Aquathermia 2. Blanket bed 2.Whirlpool bath
4. Electric cradle 4.Sitz bath
5.Electric heating Pad 5. Parafin bath 3. Electric cradle

Cold
Local General

Dry Moist Dry Moist

1. Ice cooler 1. Cold compress 1. Hypothermia 1. Cold bath

2. Ice pack 2.Evaporating 2. Cold sponging
Lotion 3. Cold packs

3. Commercial cold pack

4. Ice cradle

1) Hot water bottle/ bag:-

Water temp. – 1200 – 1490 F

2) Chemical heating bottle/ Packs :-

Temperature – 40.6 – 460C for 30 – 60 minutes

3) Infrared lamps :-
Red color lamp

4) Ultra violent lamp :-

-
 d by- Dagur ji

Blue color lamp.

5) Heating lamp :-
25 watt- 35 cm away from body part
40 watt- 45 cm
60 watt- 60 – 75 cm
6) Electric cradle :-
It is a cradle fitted with electric source & thermometer.

7) Warm soaks :-
The immersion of body parts is warm solution.

8) Hot fomentation :-
Soft material wring out & apply over the skin.

9) Stupes – (Moist)
It is a hot medicated fomentation Turpentine & Olive oil added to hot water to augment
heating effect.

10) Poultice (Cataplasm) :-

(Starch + NaHCO3) - Jelly
It is a type of moist heat Application.
Starch + NaHCo3 (Sodium bicarbonate ) Mixed apply over lint.

11) Sitz bath (Hip bath) :- Greek ward – means - seat

Bathing in a tub by immersing the area below the umbilicus.
Temperature of water 110 – 115o F (43 – 46oC)
Time of bath – 15 to 30 minute.

➢ Purpose :-
İ. To relive congestion in pelvic organ.
İİ. To reduce vaginal inflammation.
İİİ. Decrease Pain
İV. Hemorrhoids
➢ Solutions:-
İ. KMNO4 1 : 5000
İİ. Boric acid 4 – 500 ml
İİİ. Eusol (Edinburg University Solution of Lime)
12) Aquathermia pad :-
Heating unit consist of a water proof pad through which water circulate.

13) Paraffin bath :-

It include paraffin wax & mineral oil.

-
 14) Whirlpool bath: -
Full body immersion in hot solution.

15) Heating pad

16) Cold Compress: -

A cold compress is a frozen or chilled material, such as an ice pack or a pool weight
washcloth it can help to relieve pain and swelling.

17) Cold sponge: -

It is a general application of moist cold liquid to cool skin, by
evaporation and by absorption of body heat in the cold water.
e.g. Head to foot.The temp. of water in cold sponge 65 to 90o F.

Water temperature
oC oF
1. Very cold < 15 59o
2. Cold 15 – 18o 59 – 65o
3. Cool 18 – 27o 65 -80o
4. Tepid 27 – 37o 80 – 98o
5. Warm 37 – 40o 90 – 105o
6. Hot 40 – 46o 105 – 115o
7. Very Hot > 46o > 115o

ANTIDOTES
‘Greek’ word “Antididonai” – means given – Against.

Definition: -It is a chemical substance given to counter act other chemical substance.

S. Nucl. Substances Antidotes

1. Paracetamol (Acetaminophen) N-acetyl cysteine
2. Morphine / Opioids Naloxone
3. Heparin Protamine sulphate
4. Warfarin Vita. -K + fresh frozen plasma (FFP)
5. -Organophosphorus poisoning Atropine
-Mushroom Poisoning
-Neostigmine bromide
6. Atropine Physostigmine
7. Magnesium sulphate Calcium gluconate 10%
8. Potassium Sodium polystyrene sulphonate
(kayexalate)
9. Carbon monoxide (Co) Oxygen
10. Iron Deferoxamine
11. Benzodiazepine (Diazepam) Flumazenil
12. Methanol Fomepizole or Ethanol
13. Digoxin Digoxin immune Fab (Digi bind)
14. Iodine Sodium thiosulphate
15. Nitrate Methylene blue
16. Cyanide Sodium Nitrate or Sodium thiosulphate
17. Arsenic Dimercaprol
18. Lead (DMSA) or Calcium disodium edetate
19. Theophylline β Blocker
20. Methotrexate Leucovorin
21. Isoniazid Pyridoxine (vit. – B6)
22. Sulfonylurea Octreotide
(Oral hypoglycemic agent)
23. Β Blocker l Ca+2 channel blocker Glucagon
24. Unknown toxin Coma cocktail –
NaloxoneThiamine
Dextrose
25. Copper D penicillamine
26. Universal antidote Activated Charcoal

27. Insulin 50% Dextrose

28. Aspirin Force alkaline diuresis or
Furosemide + Vit.- K + NaHCo3
29. Curare Neostigmine
 ➢ Methods of body fluid transportation :-
a) Diffusion
b) Osmosis
c) Filtration
d) Active transport
A. Diffusion :-
The movement of solute from higher solute concentration to lower solute concentration .
There may or may not be semi permeable membrane.
B. Osmosis :-
-Movement of solvent across semi permeable membrane from low solute concentration
to high solute concentration.
-Osmotic pressure – The pressure that draw the solvent (water).
-Osmolality – Osmotically active particles number in per kg of water.
-Osmolality of plasma – 270 – 300 mosm/kg.
C. Filtration :-
-The movement of solute & solvent from higher hydrostatic pressure to lower hydro
static pressure.
- Hydrostatic pressure – The pressure exerted by weight of the solution.
D. Active transport (Up hill method) :-
The movement of ion/ molecule from an area of lower concentration to higher
concentration by using energy (ATP).
e.g. - Sodium & Potassium
Calcium, Iron
+
Hydrogen , some of sugar & Amino Acid
 INTRAVENOUS THERAPY – I.V. THERAPY

Types of solutions Or I.V. Fluids :-

Hypotonic Isotonic Hypertonic

Lower solute concentration A solution whose concentration ➔ Higher solute
less salt & more water is the same as other same salt & concentration more salt
water & less water
-Cellular edema - No cellular change - Cellular shrinkage
e.g. e.g. e.g.
1
1) 0.45% NS (2𝑁𝑆) 1) 0.9% NS 1) 5% GDW in 0.9% NS
1 2) 5% GDW (D5W) (GNS) (DNS)
2) 0.33% NS (2𝑁𝑆) 3) RL (Ringer Lactate) 2) 5% GDW in 0.45% Ns
3) 0.225% NS 4) 5% GDW + 0.225% NS 3) 10% GDW
1
4) Distilled water or 4%𝑁𝑆 4) 25% GDW
5) 5% GDW in RL
6) 3% NS
7) 7% NS
8) Mannitol

İ. Colloids (Plasma expander) – To increase plasma volume in shock, collapse, Hypovolemia.

e.g. 1. Dextran
2. Albumin

İİ. 0.9% NS (Normal Saline) or Physiological saline 0r Isotonic saline –

• 0.9 gm NaCl in 100 ml
• 9 gm NaCl in 1 liter
• Osmolarity = 308 mosm/L
• Na+ 154 meq/L
• Cl- 154 meq/L
• Contraindicate – Congestive Heartfailure
İİİ. 5% GDW (D5W) –
• Dextrose 5gm – 100 ml solution
• Osmolarity – 278 mosm/L
• Contraindicate – Diabetes

İV. RL (Ringer lactate)/ Lactated ringer solution/ Hartmann’s solution/ compound sodium
lactate –
Contain -
1. Sodium chloride (NaCl) 0.60gm
2. Potassium chloride (KCl) 0.04 gm
3. Calcium chloride (CaCl2) 0.027 gm
4. Sodium lactate (NaC3H5O3) 0.32 gm.

➢ Concentration of the electrolytes :-

• Na – 130 meq/L
• Cl – 109 meq/L
• Lactate – 28 meq/L
• K – 4 meq/L
• Ca – 3 meq/L
• Osmolarity – 273 mosm/L
➢ Contraindication :- Renal Failure

➔ I.V. Canula :-
1. Butter fly :-
Size = 16 – 26 G
length = 0.5 – 1.5 inch
2. Plastic Canula :-

S.N. Gauge Colour Length Flow rate Purpose

(mm) Ml/minute
1. 14 Orange 45 270 Rapid emergency Fluid
2. 16 Grey 45 200 Rapid emergency Fluid
3. 17 White 45 140 Rapid emergency Fluid
4. 18 Green 45 85 Blood transfusion
5. 20 Pink 32 55 Fat/Lipid
6. 22 Blue 25 33 Most I.V.
7. 24 Yellow 19 18
8. 26 Violet 19 10 Pediatric use
Purple
 ➢ I.V. Site :-
• Adult – forearm, hand & Anticubital fossa
• Avoid leg vein due to thrombus formation or peripheral pooling of medicine.

➢ Infant :-
• Vein of scalp & foot.
• Start distal & move upward.
• Use Non dominat hand of patient.
• Never measure blood pressure In I.V. site Arm.
• Edematous, tramatic, peralysed, infected, arterio venous fistula, surgical arm
should be avoided.
➢ Parts of the I.V. Set :-
i. Spike
ii. Drip chamber
iii. Tube
iv. Roler clamp
v. Adapter
➢ Types of I.V. set :-
(A)
i. Macro drip set – 15 (10 – 20) gtt/ml
ii. Micro drip set – 60 gtt/ml

(B)

i. Vented
ii. Non vented
➢ I.V. Container :-
• Plastic bottle – Use to label ball point pen over plastic bottle.
• Never use marker pen.
• Squeeze at the hand of plastic drip.
➢ Change timing :-
i. I.V. Sites - 72 -96 hours
ii. I.V. Sites - 96 hours (4 days)
iii. I.V. Sites -72 hours (3 days)
iv. I.V. bottle - Should not be hang over more than 24 hours.

-
 I.V. therapy Complications

1) Infection: -
The entry & multiplication of pathogenic microorganism in the body.
Local – Redness, swelling, discharge.
Systemic infection – Chills, fever, malaise, headache Nausea, vomiting, tachycardia
Intervention – Discontinuous IV line & Notify HCP.

2) Tissue damage :-
Injury to the skin, subcutaneous tissue & vein.
Intervention – Notify to Health care provider (HCP)

3) Phlebitis & Thrombophlebitis :-

Phlebitis – Red, heat, tender, vein not swollen.
Thrombophlebitis – Red, heat, tender & Hard & cord like skin.
Intervention :-
a) Stop the I.V. infusion
b) Remove Cannula
c) Notify to HCP

4) Infiltration :-
The Seepage of fluid out of vein in it interstitial space.
Signs – Pain, Swelling (edema), Coolness.
Intervention :-
Elevate, the extremity.

5) Catheter embolism :-
It is an embolism due to catheter breaking of into vein.
Symptoms :-
a) Reduce Blood pressure
b) Pain at site
c) Weak & Rapid pulse.
d) Cyanosis at nail bed.
e) Loss of consciousness
Intervention :-
• Remove I.V. Canula
• Place tourniquet
• Notify to HCP
• Plan for X-ray & Surgery.

-
6) circulatory overload :-
The excess of fluid in the circulation.

Sign/ symptoms :-
• Increase blood pressure
• Distended Jugular vein
• Dyspnea, Rapid breathing
• Moist cough, crackle

Intervention :-
• Slow the flow rate
• Elevate head of the bed.
• Notify to the physician.

7) Electrolyte overload :-
• Intervention :- Monitor signs & symptoms of particular electrolyte overload.
• Notify to the physician.

8) Hematoma :-
The collection of blood into tissue as a result of unsuccessful Venipuncture.
Signs & Symptoms :-
• Ecchymosis (skin discoloration) (Red) due to blood stagnation beneath the skin.

Intervention :-
• Elevate the extremity.
• Apply pressure.
• Ice as prescribed.

9) Air embolism :-
Bolus of the air in the vein causes embolism.

Signs & Symptoms :-

• Decrease blood pressure
• Cyanosis
• Decrease level of consciousness
• Tachycardia
• Dyspnea
• Chest pain
Intervention:-
i. Clamp the tubing.
ii. Left lateral Trendelenburg position.
iii. Notify the physician.
iv. 100% O2 (HBOT) Hyperbaric O2 therapy.

MEDICAL SURGICAL ASPSIS

1) Infection :-
The entry & multiplication of pathogenic Agent in the body.
2) Asepsis :-
Freedom from infection.
3) Antiseptic :-
An agent that prohibit growth & development of microorganism without killing
them.

4) Bacteriostat :-
An agent prohibit growth & development of Bacteria.
5) Bacteriocide :-
An agent which kills the bacteria.
6) Nosocomial Infection :-
The infection originated or Acquired in hospital.
7) Iatrogenic infection :-
The infection originated as a result of diagnostic & therapeutic procedure.

8) Cross infection :-
The infection transmitted between individuals.
9) Contamination :-
The act of soiling or make dirty.

10) Complication :-
New illness arise during disease course.

11) Colonization :-
The invasion grow & multiplication of micro organism in the host.

12) Disinfection :-
A process of killing the all pathogenic microorganism.
13) Disinfectant :-
An agent that kill pathogenic microorganism.
14) Sterilization :-
A process by which surface, medium, articles made free from all type of micro
organism. (Pathogenic & Non Pathogenic.)
15) Isolation :-

-
 Separation of infected person from Non infected person.
16) Quarantine :-
Detention or isolation of healthy person (Non infected person) who have come in
contact with infectious disease. (Infected person)
17) Sepsis :-
Infection with pus forming bacteria.
18) Prophylactic :-
The measures taken prior to prevent diseases.
19) Virulence :-
Micro organism’s ability to produce disease.
20) Portal of entry :-
The pathway from which microorganism can enter into body.
21) Portal of Exit :-
The pathway from microorganism can leave the body.
22) Fomites :-
Contagious objects that can transmit disease.

A. Medical Asepsis :-
All practices used to eliminate pathogenic organisms.
Clean technique used.
B. Surgical Asepsis :-
All practices used to eliminate pathogenic & Non pathogenic organisms.
Sterile technique used.
➢ Hand Washing :-
• The most important aspect of medical surgical asepsis.
• It should be done before & after every procedure.

Medical asepsis Surgical asepsis

Water should be run from elbow to Water should run from hand to
Hand elbow.
Time – At least 15 sec. 3 to 5 minute
Scrub – 5 to 10 minute.

➢ PPE --- Personal Protective Equipment :-

Wearing Removing
(A) Hand washing (1) Gloves
(B) Grown (2) Eye wear
(C) Mask (3) Gown
(D) Eye wear (4) Mask
(E) Gloves (5) Hand washing

➢ Principles of Surgical Asepsis :-

-
 i. Always face the sterile field never turn back site.
ii. Never reach across the sterile field.
iii. Avoid speaking, sneezing, coughing over sterile field.
iv. Avoid dusting & sweeping over sterile field.
v. Edge of sterile field are considered as unsterile.
vi. Keep the sterile equipment above the waist level.

➢ Disinfection :-
Types-
1. Concurrent disinfection :-
Immediate & as soon as possible disinfection of articles & body discharge of the
patient.
2. Terminal disinfection :-
The disinfection of articles & client’s unit after discharge, transfer & death at the
end.
3. Pre current / prophylactic disinfection :-
Disinfection done to prior to prevent disease.
e.g. Purification of water, Pasteurization of the milk.

Sterilization

Physical Chemical

Sunlight Heat Ozone Radiation Filtration

Dry heat Moist heat

Red Flaming Incineration Hot Air oven

Temp. <100o At 100o C Temp. >100oC

Pasteurization Boiling Autoclave

-Inspissation Tantalization
-Vaccine bath

-
 1. Physical Sterilization :-
A. Sunlight
It contain UV rays which is germicidal.

B. Heat
➔ Dry Heat –
1. Red Heat :-
Kept an object in flame until it become red.
e.g. inoculating loops/ wires.
Tips of the forceps & needles.
2. Flamming :-
The object passed through flame.
e.g. Glass slide, scalpels mouth of culture tube.
3. Incineration :-
It is a high temp. dry oxidation ……… method in which material reduced to ash
by burning e.g. Soiled dressing, bedding, pathological material, human & Animal
anatomical waste.
4. Hot Air oven :-
It is a electrically heated oven.
Temp. 1600 C for 2 hour
170o C for 1 hour
180oC for 30 minute
• Glass ware – Glass syringe, Petridis, Pipette
• Surgical items – Scalpels, scissors, forceps
• Chemical – liquid paraffin, Sulfonamide powder.

5. Moist Heat :-
i. < 1000C
a) Pasteurization of Milk –

Types

a. Holder (Vat) 63oC – 30 minute.

b. Flash method 72oC for – 20 minute.
b) Inspissation –
80 – 85oC for 30 Minute for 3 consecutive days.
Serum & egg culture media.
c) Vaccine bath –

-
 60oC for 1 hour.
e.g. Sterilization of the bacterial vaccine.
ii. At 100o C

a) Boiling –
• 100oC for 10 – 30 minute.
• Sharp instrument should not be sterile by the boiling method.

b) Tantalization –
• At 100o C for 20 minute (steam) on three successive days
sterilization done also known as intermittent sterilization.
e.g. Serum, Sugar culture media.

iii. > 1000 C

Auto clave (steam under pressure ) :-

Temp. 121oC – 15 lbs/inch2 15 minute.
126oC – 20 lbs/inch2 10 minute.
133oC – 30 lbs/inch2 3 minute.
➢ Uses :-
• Culture media, gloves
• Rubber items
• Dressing
• Surgical instrument except sharp items.
• Gown
C. Ozone sterilization :-

• Used in industrial setting to sterile air & water.

D. Filtration :-
A method of sterilization of using a filter 0.75 um ( micrometer)
Use – Sera, Sugar, antibiotic solution, water purification.

E. Radiation :-
i. Type A – Ionizing Radiation

e.g. Gamma Radiation-

Sterilization of the disposable items like plastic syringe , Catheter, Cannula swab,
culture plate

ii. Type B – Non Ionizing Radiation

1. Infra Radiation – Catheter & syringe.

-
 2. Ultra violet rays

* Operation theater bacteriological laboratories.

2. Chemical sterilization :-
a) Alcohol –
▪ Ethyl alcohol
▪ Isopropyl alcohol
Use – Skin disinfection

* 70% alcohol known as spirit.

b) Aldehyde :-
• Formaldehyde
10% aqueous solution of the formalin.
Function – Preservation of the tissue, sterilization of bacterial vaccine.
• Glutaraldehyde – 2% (Cidex)
Function – Disinfection of bronchoscope cystoscope endoscope, plastic
endotracheal tube, metal instrument.

c) Phenol (Carbolic Acid ) :-

i. Cresol :-
▪ The soap solution of cresol known as Lysol used for floor cleanliness &
Disinfection of excreta.

* 5% cresol sharp instrument.

ii. Chlorhexidine + Cetrimide – Salvon 2% or 5%

Function – Skin disinfection .
iii. Chloroxylenol (Dettol 4%)
Function – Skin disinfection.

d) Halogens:-

a) Chlorine
▪ Bleaching powder or Chlorinated line.
- 5% Bleaching powder used for disinfection of feces & urine (human excreta)
▪ Sodium hypochlorite or Household bleach
Mostly widely used for HIV infected material (10%)

b) Iodine :-
2% Betadine – Skin disinfection & dressing.

e) Oxidizing agent :-

a) H2O2 – Hydrogen peroxide

-
 o Dressing
o Contact lens
o Plastic implant
b) KMno4
1 : 5000 – Mouth care
- Sitz bath

f) Dyes: -

Acriflavine - Skin disinfection

Gentian violet - Skin disinfection

g) Vapour phase disinfection :-

(i) ETO – Ethylene oxide

o it is colorless liquid.
o Co2 & H2O added to ETO to reduce its explosive
tendency.
➢ Use :-
Plastic & rubber, items, disposable plastic syringe, sutures, heart lungs
machine, cardiac catheter.

_
(ii) Fumigation 𝒄 Formalin
280 ml formalin – 1000 Cubic feet area.
+
150 gram KMNo4
• Operation theatre
• Wards
• Laboratory
• The area should be sealed off 48 hour.

(iii) Fumigation with Sulphur—220 gm Sulphur 100 cubic feet.

Material Method of Sterilization
1. Inoculation wires /loops Red heat.
2. Glass ware Hot Air oven
3. Disposable syringe & other items Gamma Radiation & ETO
4. Apron, gloves, gown, dressing Autoclave
5. Cystoscope, Endoscope, Glutaraldehyde (Cidex 2%)

-
 Bronchoscope
6. Egg & Sugar culture media Tantalization Inspissation
7. Operation theater UV rays or fumigation
8. Milk - Pasteurization

CLIENT UNIT
➢ Ideal requirement :-
1) Temperature - 20- 220C
2) Humidity - 40 – 60%
3) Air movement - 15 – 45 feet/ minute
or 1 – 3 mile/hour
➢ Size :-
1. Bed/ co – 78” (length) × 38” (Wide) × 28” (Height)
2. Mattress - 190 cm (length) × 90 cm (wide) × 10 cm (thickness)
3. Bed sheets/ Bed lines - 108” (length) × 76” (wide)
4. Draw sheet - 150 × 110 cm
5. Pillow - 60 × 45 × 10 cm
6. Pillow cover - 65 × 50 cm
➢ Bed making :-
i. Place the pillow on the chair, on the bed with open end away from the entrance unit.
ii. Fold the bed sheets into 6-fold.
iii. Fold the draw sheets into 3-fold & Place it 25 cm away from head end.
iv. Mackintosh do not fold. Roll it. Place 37 cm away from the head end.

➢ Types of bed :-
1) Close bed :-
• The empty bed
• Bed spread cover all linen.

2) Open bed :-
• The bed is about to be occupied.
• Top linen folded back at one corner.

3) Admission bed :-
• The bed is made as open bed. The patient gets into after bath &
changinginto hospital uniform.

-
4) Occupied bed:-
• The bed with patient.

5) Operation/ Post anesthetic/ Recovering bed :-

The bed is prepare the person who is recovering from anesthesia after the surgery.
• Extra mackintosh
• No pillow

6) Cardiac bed :-
The bed is prepare to assume cardiac position.
• Extra pillow
• Back rest
• Cardiac table

7) Fracture bed :-
• For the fracture patient.
• Extra pillow
• Balkan Frame ( To give Traction )
• Divided mattress

8) Amputated / Stump/ Divided bed:-

• For the easy visualization & dressing of stump.
• Extra sheet, sand bag.

9) Blanket Bed :-
• For the Rheumatism.
• Renal disease.
• Two blanket under & over the patient to provide warmth & promote
elimination to the skin.

-
 PRESSURE ULCER
Also known as Pressure sore or Bed sore or Decubitus Ulcer.

➢ Definition :- A localized injury to skin & underlined tissue over bony prominence as a
result of pressure or pressure in combination with fraction or and shearing.

➢ Common site :-

(A) Fowler position → (C) Prone position

1) Vertebra 1. Cheek & ear
2) Sacrum 2. Shoulder
3) Pelvis 3. Breast
4) Heels 4. Genitals
5. Knees
6. Toe
(B) Supine position → (D) Side lying
1) Occipital Bone 1. Side head
2) Scapula 2. Ear
3) Sacrum 3. Shoulder
4) Elbow 4. Ilium
5) Heels 5. Greater trochanter
6. Knee (Medical & lateral condyle)
7. Malleolus (medical & lateral )

➢ Braden Scale :-
• Braden scale invented by Barbara Braden & Nancy Bergstrom 1987.
Purpose → Predicting the ulcer risk.
• 6 Sub scale.
1. Sensory perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction & shearing

➢ Score :-
• Minimum -6
• Maximum - 23

➢ Result :-
1. 19 – 23 --- No Risk
2. 15 – 18 --- Mild Risk
3. 13 – 14 --- Moderate Risk
4. 10 – 12 --- High Risk
5. ≤9 ------ Very High Risk.

-
 ➢ Etiology & Risk factor of ulcer sore :-
1. Ischemia
2. Pressure
3. Moisture
4. Friction & Shearing
5. Immobility
6. Impaired Nutrition
7. Diminished mental status
8. Decrease sensory perception
9. Advance Age
10. Chronic medical condition

➢ Classification :-
1) Stage I - Non blanchable erythema
• Skin intact, pain & warmth.
2) Stage II – Partial thickness skin loss or blister.
• Epidermis & partial dermis damaged.
3) Stage III – Full thickness skin loss (Fat visible)
• Epidermis, dermis & subcutaneous tissue damage.
4) Stage IV – Full thickness tissue loss (muscle & bone visible)
• Epidermis, dermis, subcutaneous tissue, bone, Tendon, Muscles damage.
5) Unstageable / Unclassified
• Full thickness tissue loss in which actual depth obscured by slough.

➢ Treatment :-
1. Notify the HCP.
2. Change the position.
3. Dressing with sterile technique.
_
4. Clean the wound 𝑐 NS.
5. If pus – H2O2 (Hydrogen peroxide)
6. Wound healing

A. Hot Application – 100 watts.

_
45 – 60 cm away 𝑐 10 minute.
B. Insulin drops
C. Water proof ointment
Zinc oxide (ZnO)
D. Granulated Sugar

-
 OXYGEN THERAPY
Administration of the O2 to meet O2 need of the body.
➢ Indication :-
1. Dyspnea
2. Respiratory problem
3. MI
4. Extensive burn/ major burn
5. Anemia
6. High grade fever
7. Shock etc.

➢ Method of O2 / O2 delivery system :-

1. Nasal canula (Nasal prongs)
▪ Low flow rate ls O2 nsrs gSaA
▪ Chronic air flow limitation & long term used.
▪ Flow rate --- 1 – 6 L/Minute.
▪ O2 concentration – 24 – 44%
▪ Friction of inspired O2 = 24 – 44%
1. L/M = 24% 4. L/M = 36%
2. L/M = 28% 5. L/M = 40%
3. L/M = 32% 6. L/M = 44% L/M – liter/Minute

2. Nasal Catheter :-
▪ Change the position after every 8 hours into opposite Nostril.
▪ Flow rate = 1 – 6 L/M
▪ O2 Concentration = 24 – 44%

3. Face Mask :-
Simple Face Mask :-

Short term use or in emergency.

▪ Flow rate = 5 – 8 L/M
▪ O2 Concentration = 40 to 60%

a) Partial Rebreather Mask :-

1
▪ It is mask Reservior beg which allow 3 of exhale Air to rebreathe.
▪ Flow rate = 6 – 15 L/M
▪ O2 concentration = 70 – 90%
b) Non Rebreather Mask (NRB) :-

-
 ▪ It is a plastic mask with Reservoir beg.
▪ It consist one way valve which prevent Room Air & Exhale air enter
into beg.
▪ Highest percentage of O2 delivery system.
▪ Flow rate = 10 – 15 L/M
▪ O2 Concentration 95 – 100%
▪ Detoriating Respiratory states & the patient who require intubation.
▪ Highest concentration of O2 can be given.

c) Venturi Mask (Venti Mask / Air entrainment mask) :-

▪ It is a mask attached with venture device that mix specific volume of
room air.
▪ Colour coded Jet adaptor.
Colour Flow Rate (L/M) %O2
1. Blue 2 24
2. White 4 28
3. Orange 6 31
4. Yellow 8 35
5. Red 10 40
6. Green 15 60

▪ O2 Concentration = 24 – 60%
▪ Acute Respiratory distress.
▪ Most Accurate O2 delivery system.
4. Face tent :-
Use
• Facial trauma & Burn.
• Flow rate 4 – 8 L/minute.
• O2 Concentration 30 – 50%.

5. Oxygen tent :-
• It is plastic canopy fitted over patient bed.
• Paediatric use.
• Flow rate = 10 – 15 L/M

• O2 Concentration = 30%
6. Oxygen hood :-
• A plastic dome that enclose infant head.
• Flow rate 10 – 15 L/minute.
• O2 Concentration = 80 -90%

7. Transtracheal catheter :-
• A catheter inserted directly through surgically created track in the trachea.
1
• Flow rate -- 4 to 4 L/minute.
• O2 Concentration – 22 – 45%
• In the tracheostomy O2 can be given by T piece or T-coller.
➢ Oxygen Cylinder :-
-
 • Pressure – 2200 Pound/inch2 or
1000 kg/inch2
• In pipe supply – 50 -60 Pound/inch2
• Humidifier (Wolf’s bottle )
It prevents mucus membrane. from drying & becoming irritated & loosen
secretion foreasy expectoration.
• O2 gas supports combustion (Fire).
• Color-
i. O2 → Top – White, Body – Black
ii. N2O (Nitrous Oxide ) – Blue
iii. CO2 – Grey
iv. Cyclopropane - Orange
v. Helium – Brown

➢ Complication of O2 therapy :-

1. Retrolental fibroplasia (Retinopathy of Prematurity)

• Premature New born.
• The growth of blood vessels causes scaring & Retinal detachment result in
blindness.
2. Infection
3. O2 toxicity – 60% for 24 hours above.
4. O2 induce apnea - CO2 dh ek =k de gks tkrh gSA
5. Atelectasis -
Excess O2 N2 Alveoli ls fudy tkrh gSaA
6. Dryness of Mucosa.

-
 TRACHEOSTOMY
An artificial opening made into brachia to maintain & establish a patent airway.

➢ Indication :-
1. Obstruction in the upper respiratory tract-
A. Oedema
B. Tumor
C. Foreign body

2. Injury to head, neck, facial & chest

3. Intolerance to the endotracheal tube
4. Neurological disorder
5. Respiratory failure
6. Cancer of the larynx.
➢ Classification of the tracheostomy tube Procedure :-
Acc. to placement

High Low

L2-L3 L3-L4

Acc. to Situation

Planned / Prophylactic Emergency

Horizontal cut is given Vertical cut is given

(With all instruments) (Fast work load)

 opportunities never happen, we create them

Acc. to Duration

Temporary Permanent

Plastic tube is used Metallic tube is used

➢ Types of Tracheostomy tube :-

(1). Double lumen Single lumen

(2). Cuffed Non Cuffed

(3). Fenestrated Non Fenestrated

Cuff pressure – 20 mm/hg

- 25 cm H2O

➢ Parts of Tracheostomy :-
1. Outer Cannula - It is outer tube that holds the tracheostomy open.
2. Inner Cannula – It has a lock to keep it from being coughed out. It also helpful during
tracheostomy tube.
3. Obturator – It is used to insert tracheostomy tube. It is a styletor pilot.

➢ Incision: -

-
 Vertical & Horizontal given at interior border cricoid cartilage 1% lidocaine
with1 : 1000 epinephrine Solution.

➢ Procedure: -
1. Position
Supine with hyperextension of Neck (Rose position)
After tracheostomy – fowler position

2. Suctioning-
a) Suctioning pressure-
- Infant - 60 – 80 mm/hg
- Child - 80 – 100 mm/hg
- Adult - 100 - 120 mm/hg
b) Suction Catheter size –
- Infant - 5–8
- Child - 8 – 10
- Adult - 12 – 18
c) Hyper oxygenate - the person with 100% before Suctioning.
d) Suctioning time - 5 – 10 sec
Maximum - 10 sec
e) Applying Suction -
Intermediately Routing
When withdrawing

➢ Suctioning Time :-
First 24 hrs. - After every 30 min
After 24 hrs. - Every 2 hrs.
➢ Formula of Selection :-
More than 1 yrs.
𝐴𝑔𝑒
[( 4 ) ]
+ 4.5 × 4 + 2

➢ Instrument:-
• 1% Lidocaine with 1: 1000 epinephrine
• Tracheal dilator
• Double hook retractor
• Surgical blade

-
 • Tracheostomy tube
• Tracheostomy set.

➢ Chemical solution :-
• Normal saline 0.9%
• Sodium bicarbonate
• H2O2
• Betadine 5%

➢ Basic care during the tracheostomy :-

• Commonest problem - Unable to speak if patient say that he wants to speak than cover.
• Use Vaseline gauze to prevent skin erosion.
• Stoma should be clean & apply antibiotic ointment
• Assess the Stoma for Purulent drainage.
➢ Decannulation :-
The process of removal of Tracheotomy Tube.
➢ Inner cannula should be clean after every2 – 4 hours. With H2O2, NaHCO3, 0.9%NS.
➢ Stoma should be clean & Apply Antibiotic ointment & Vaseline gauze should be use.

➢ Complication Tracheostomy:-
a) Tracheomalacia
Tracheal dilation & erosion.
b) Tracheal stenosis →
Narrowing of trachea.
c) Trachea esophageal fistula (TEF)
Abnormal opening B/w trachea & esophagus.
d) Trachea innominate artery fistula →
Abnormal opening B/w trachea & innominate artery.
e) Tube obstruction
f) Tube dislodgment
 ENDOTRACHEAL TUBE INTUBATION
The insertion of endotracheal tube through the mouth or nose into trachea to establish &
maintain the paten airway for short period. (10 -14 day)
➢ Purpose :-
a) To maintain patent airway.
b) To administer O2.
c) Airway suctioning.
d) To give anesthesia.
e) To administer drugs. - e.g. Bronchodilator, Epinephrine, Atropine
➢ Procedure :-
a) Head tilt & Chin lift position.
b) Insert oral tracheal (commonly ) nasotracheal.
c) Infuse 5 to 10 ml air.
d) Cuff pressure 20 -25 mm of Hg.
e) Monitor pressure every 8 hourly by Hand held manometer.
f) Size –
• New born - 2.5 – 4mm
• Infant - 4 -4.5 mm
• Child - < 10 yr = 5 – 7 mm
• Child - > 10 yr = 7 – 8 mm
• Adult - 8 – 9.5 mm
• Man - 7 – 9 mm (Average 8 mm )
• Women - 6.5 – 8.5 mm (Average 8 mm)
Formula (Size)
𝐴𝑔𝑒
> 1 year = 4 +4

Length = 1 cm
𝐴𝑔𝑒
Oral = 12 + 2

-
 𝐴𝑔𝑒
Nasal = 15 + 2

➢ Placement of ET :-
1. 1 – 2 cm above carina.

2. Confirmative placement should be checked by X-ray.

• Bilateral Lung Sound & chest rise visible.
• If the tube in stomach then louder sound heard over stomach then the lung sound,
abdominal distension.

NASOGASTRIC TUBE (NG TUBE) RYLE’S TUBE

Insertion of a tube through Nose into stomach.

➢ Purpose :-
i. Tube feeding (Gastric Gavage)
ii. Gastric suctioning or Irrigation _-- Gastric lavage
➢ Procedure :-
İ. High fowler position with Head forwarded.
İİ. Measure the tube from tip of Nose to earlobe to xiphoid process
İİİ. Lubricate the tube 3 – 5” inch with water soluble jelly (Oil soluble
jelly may cause chemical pneumonia)
İV. Preferable insert into Left Nostril.
V. If the client show respiratory distress ( choking/ coughing) then
pull back & wait.
Vİ. Checked the placement –
• By X-ray
• Aspirate the gastric content & check pH less then 4 (<4)
• Keep the tube in bowel of water if bubbling present means
wrong placement.
• Infuse 10 ml air & heard its sound over, stomach (Whoosh
sound.)
Vİİ. Deep breath & hold. Remove the tube 3 – 6 second. (NG
Extubution)
➢ Size :-

Adult - 16 – 22 French
Child - 10 – 14 French
Infant - 4 – 10 French
➢ Types of Tubes :-
1. NG Tubes –

-
 a) Levin tube –
• Single lumen tube used for tube feeding & suctioning.
b) Salem sump –
• It is a double lumen tube.
• It consists air Vent & suctioning port.

2. Intestinal tube:-
a) Cantor tube – Single lumen tube
• Used in intestinal decompression.

b) Harris tube – Single lumen.

• Used in intestinal decompression.

c) Miller Abbot tube -

• Double lumen tube.
• One to inflate stomach balloon.
• Second to drain or irrigate the small intestine.
3. Esophageal gastric tube :-
a) Sengstacke Blakemore tube
• It is triple lumen tube.
• One to inflate esophageal balloon.
• To inflate stomach balloon.
• For suctioning.

✓ Used in esophageal varies (Esophageal bleeding)

✓ Always keep scissor at bed side.
b) Minnesota – 4 lumen tubes.

4. Lavage tube :-
a) Ewald - single lumen tube.
b) Evacuator tube - Double lumen tube.

❖ Keeps Points N.G. Tube :-

• Always measure Residual volume before feeding.
• If the volume more than > 100 ml then delay feeding.
• Again, rein still the aspirate volume.
• Mixed the medicine with 15 – 30 ml water then instill 30 – 35 ml NS/Water & then
clamp the tube for 30 – 60 minutes.
 URINARY CATHETERIZATION
➢ Definiation :-
Insertion of a catheter into bladder through urethra for various purpose.
➢ Purpose:-
a) To drain urine.
b) For bladder irrigation.
c) To collect urine sample.
d) After the surgery.
➢ Types:-
1. Indwelling / Retention
• The Catheter is kept for𝐷𝑜𝑢𝑏𝑙𝑒
a period of time in bladder.
𝑙𝑢𝑚𝑒𝑛
e.g. Foley’s catheter < 𝑇𝑟𝑖𝑝𝑙𝑒 𝑙𝑢𝑚𝑒𝑛
2. Straight Catheter –

• The catheter used for very short period of time.

e.g., K-90
3. Suprapubic Catheter –
• Catheter inserted into bladder through incision made on anterior abdominal
valve.
e.g. – Malicot
- Pezzer (Mushroom Catheter)
4. Ureteric Catheter –
A Catheter passed into renal pelvis with the help of cystoscope.
Coude Catheter (Curved tip) – Used in enlarge prostate.

➢ Retention Time:-
1. Plastic catheter - Up to 1 week.
2. Rubber/ Salastic/ Latex - 2 – 3 weeks.
3. PVC (Poly Vinyl Chloride Catheter) - 4 – 6 weeks.
 4. Silicon Catheter - 2 - 3 month.
➢ Procedure:-
1) Maintain strict sterile technique.

2) Position-
Male – Supine with leg abducted (slightly) Penis pull upward & forward at 90%.
Female- Dorsal Recumbent position.

3) Clean the genital-

Male – Clean the penis in circular motion center to outward.
Female- Clean from front (above urethral opening) to back.
• Dry sterile cotton use to clean.

4) Insert
Male – 7 – 9-inch (17 – 22.5 cm)
Female – 3 inch (7.5 cm)

5) Lubricate
Male – 6–7-inch
Female – 1 – 2 inch

6) Water soluble jelly

7) Used sterile water to inflated the ballon because saline crystalize & result in incomplete
deflation.

8) Catheter size :-
Adult male - 16 -18 French
Adult Female - 14 -16 French
Child - 8 -10 French
Infant - 5 -8 French

9) Anchor catheter at inner upper high.

URINE TEST
 1) Test for Sugar - Benedict’s test
5 ml Benedict solution

3 Drop Urine

Boil & Cool

➢ Result :-
i. Blue Nil Sugar
ii. Green 1% sugar
iii. Green with yellow deposit 2% Sugar
iv. Colorless liquid with orange deposits 3% Sugar
v. Brick red color 5% Sugar
vi. Sucrose does not give positive result for benedict solution.

2) Test for Acetone – (Rothera’s test)

Ammonium Sulphate

Add the Urine

Sodium Nitroprusside (1 crystal)

Shake

Liquid Ammonia

Result: - Purple color ring formed at junction of ammonia & urine means positive acetone.

3) Test for Bile salts – (Hey’s test)

Urine
 + Sulphur

Result:- It Sulphur sink down means bile salt present.

4) Test for Bile pigment ( Smith’s test ) :-

Urine

Iodine

Result :- A green color ring formed at the junction of Iodine & urine means bile pigment present.

5) Test for Albumin: -

A. Hot test –
Boil the Urine

Clouds

Albumin Phosphate

Acetic + Acid

Cloud Cloud clear

Albumin present Phosphate Present

B. Cold test –
Urine

Nitric Acid
or
Sulphosalic Acid 3%

White precipitation

Albumin present
 WATER SEAL DRAINAGE OR CLOSE CHEST DRAINAGE
Drainage system to remove abnormal accumulation of air/ fluid (Blood, pus, lymph, serous fluid) from
pleural space.

➢ Purpose :-
1. To remove air & Fluid from pleural space.
2. To return normal Negative pressure of pleural space.
3. To re-expand the lungs.
4. To treat pneumothorax (Air).
• hemothorax (Blood)
• Hydrothorax (Serous fluid)
• Chylothorax (lymph)
5. In thoracis surgery.
➢ Water seal Appratus :-
a) Drainage bottle –
It is connected with chest tube to collect the drainage.
b) Water seal bottle –
It contains water/NS 100 ml. It makes a seal which prevent of atmospheric
airenter into pleural space.
c) Suction control bottle –
Connected to suction to provide negative pressure.

➢ Intervention:-
1) Monitor the amount of drainage. If the amount is > 70 -100 ml/hour notify the physician.
2) Water seal bottle – Water oscillate Rise during Inspiration.
Fall During Expiration
• Intermittent bubbling - Normal
• Continuous bubbling - Air leakage

(Water) Oscillation stops

 opportunities never happen, we create them

• Lung has re-expanded

• Suction is not working.
• Tube is obstructed.
• Too long tube (Loop presented)
3) Suction control bottle: -
• Gentle bubbling - May present
• Vigorous bubbling - Air leakage

4) Apply occlusive sterile dressing at the puncture site.

5) If the tube is pulled out then pinch the skin together & apply occlusive dressing.
6) Keep drainage system below the chest level.
7) Maintain fowler position.
8) To drain Air - 2Nd intercostal space (Upper & Anterior)
To drain fluid - 8th /9th intercostal space (Lower & Posterior)
9) To remove chest tube, ask patient to perform Valsalva maneuver (Deep breath exhale &
beardown)

THORACENTESIS

A process of removal abnormally accumulated air/fluid from the pleural space by puncture
pleural cavity with needle.
• It may be for diagnostic and therapeutic purpose.
• For diagnosis aspirate 20 -30 ml.
• For therapeutic purpose drain more than 1000 ml (circulatory failure or cardiac failure.

➢ Common site :-
• 7th or 8th inter costal space below the inferior angle of scapula.
• Not below 9th inter costal space.

➢ Needle size :-
16 Gauge.

-
 PERICARDIOCENTESIS/ PERICARDIAL ASPIRATION
➢ A process to drain pericardial fluid sites :-
• 4th/5th/6th intercostal space in between xiphoid process & left subcostal space with angle 25 -35o.
• Needle size – 14 -18 Guage.
• Artificial opening made into colon abdominal was on anterior to escape flatus & feces.

COLOSTOMY
➢ Indication :-

1) Large intestine obstruction.

2) Permanent means evacuation in trauma, disease birth defect tumor.

➢ Types of clolostomy :-
a) (i) Temporary - Short term/ period.
(ii) Permanent - Long term/ period – usually at descending colon.
b) (i) Wet colostomy - Right side in ascending colon. Fecal content semisolid.
(ii) Dry colostomy - Left side descending or sigmoid colon – (Commonly use) Fecal
content solid.
c) End colostomy:-
A stoma is made at the end the colon. The remaining colon segment known as
Hartmann’s pouch.
d) Loop colostomy –
A loop made over anterior abdominal wall & keep in place with external
supporting device.

e) Double barrel colostomy –

It is two stoma –
(i) Proximal - for stool
(ii) Distal - Mucus

-
 opportunities never happen, we create them

➢ Intervention :-
A. Preoperative-
i. Give low residue diet 1 -2 day before colostomy.
ii. Give interstinal Antibiotic.
iii. Administer Laxative or enema.

B. Post operative –
i. Apply petroleum jelly followed by dry sterile dressing over stoma.

ii. Monitor stoma colour.

Pink, Red - High vascular (Normal)
Yellow stoma - Low Hemoglobin
Black/Purple stoma - Circulation
compromises.Notify to HCP.

Monitor consistency of fecal matter.

1. Ascending - Liquid
2. Transverse - Semisolid
3. Sigmoid - Normal.

iii. Empty the colostomy bag when IT Fill 1 3

iv. Avoid gas forming & odor producing food.

LIVER BIOPSY
Liver Biopsy is a procedure in which a small needle is inserted into the liver to collect a tissue sample.

➢ Indication/ Purpose :-
Cirrhosis of liver [Most confirmative]
- Autoimmune hepatitis
- Chronic hepatitis
- Hematochromatosis [Too much iron in the blood]
- Alcoholic liver disease
- Non-Alcoholic liver disease
- Wilson’s disease [An inherited & degenerative liver disease caused by
excesscopper in the body]

Liver Biopsy

Open liver Biopsy Closed liver Biopsy (Most common)

[ If surgery is going then take biopsy ] [ Percutaneous liver Biopsy]

- It is done under General Anesthesia. - It is done under local Anesthesia.
➢ On the basis of site :- Liver biopsy is classified into three types :-
1. Percutaneous –
Also called a needle biopsy. This biopsy involves putting a thin needle
throughthe abdomen & into the liver. [Most common Method]
2. Transjugular –
This procedure involves making a small incision at neck. A thin flexible tube is
inserted through the neck’s Jugular vein & into the liver.
◼ It is used for bleeding disorder.

3. Laparoscopic –
 This techniques use tube like instrument that collect sample through incision in
the abdomen. [ Under G.A.]
Biopsy Needle

Suction Needle Cutting Needle Spring loaded

(1) Mengnini (1) Vim-Silverman Spring loaded
Needle cutting needle that
have a triggering
mechanism
(2) Klat skin Needle (2)Tru-cut
(commonly used)

BONE MARROW AISPIRATION

Bone Marrow aspiration is a procedure that involves taking sample from the soft tissue inside your bones.
Bone Marrow is the spongy tissue found inside bones. It contain cells that produces WBC, RBC, Platelet
inside the larger bone like – Breasl bone, Spine, Illiac bone etc.

➢ Indication :-
• To detection Anemia.
• To detect bone marrow disease – Myelofibrosis, Myeloblastic syndrome
• hemochromatosis [More iron in blood]
• Infection like T.B.
• Storage disease like Aonyloidosis or Gaucher disease
• Help to detect Bone Marrow Problem , Cancer.

➢ Site :-
1. Sternum – Upper part of sternum ( Supine Position)
2. Iliac Crest [Commonest site]

Anterior Posterior
(Common) (Prone)
Lateral Position
3. Limber Spine :- Knee chest [Fatal attitude position]
L3 – L4
L4 – L5

4. Candyl of Femur & Tibial bone –

 Commonest below 2 years.
Quantity of sample - 0.2 ml

➢ Needle :-

Klima needle Jamshidi needle

➢ Complication :-
• Pain
• Bleeding
• Injury to the diaphragm

➢ What should be kept in mind before liver biopsy :-

1. Done pre test – BT, CT, PT, INR
Bleeding time - 2 -6 minute
Clothing time - 8 -15 minute.
Prothrombine time - 9.6 to 11.8 sec.
2. Stop taking any medication that affect bleeding & pain.
3. Not drink or eat for up to eight hours before the procedure.
4. Arrange for someone to drive you home.
5. Give psychological support to avoid anxiety.
➢ Procedure :-
• Hospitalize - before 24 hours.
• Articles
o Biopsy needle
o Preservatives [10% formaldehyde]
o Anesthesia
o Sprit
o Betadine
➢ Site:- th
8 - 9 th Inter costal space.

What should be kept in mind before renal Biopsy :-

✓ Same as liver biopsy. Except position [prone]

➢ Procedure :-

-
 Same as liver biopsy except needle
Fine needle [16 gauge]
Spring loaded.
➢ Site :-
Below the ribe.
1
11th ribs to 2 space flank region.
➢ Position:- Before renal biopsy.
- Prone position.

➢ Care after renal biopsy :-

• Supine position after renal biopsy.
• Rest in bed 12 to 24 hrs.
• Avoid blood thining medication.
• Follow doctor instruction.
• Report any problem-
- Bloody urine for more than 24 hrs after the biopsy.
- Unable to pass the urine.
- Fever & Bleeding from puncture site continuous.
- Worsening pain at the biopsy site.

Renal Biopsy

Renal biopsy is a procedure in which a small needle is inserted into the Renal to collect a tissue sample.

➢ Indication :-
1. Determine kidney tumor is Malignant or Benign
2. Transplanted kidney is working or not.
3. Cause of hematuria sproteinuria we can detect.
4. Detection of severity of kidney failure.
5. Create treatment plan for diseased Kidney.

Types

Open Renal biopsy Closed Renal biopsy

if surgery is going than take the tissue. [Percutaneous] most common

-
 Lumber Puncture
Lumber Puncture is also known as “Spinal tap”.

It is done first time in 1891 German Physician Heinrich Quincke”

➢ Definition :-
A needle is inserted between two lumber bones (vertebrae) to remove a sample of
cerebrospinal fluid – The fluid that surrounds you brain & spinal cord to protect
them form injury.

➢ Indication :-
• To diagnosis Meningitis,
• To diagnosis encephalitis.
• To diagnosis Guillian bore syndrome.
• To diagnosis Multiple sclerosis.
• To diagnosis Cancer of brain.
• Give anesthetic drug or chemotherapy drug.
• Sub arachnoid hemorrhage.
• Increase ICP
• T.B. in C.N.S.
• Seizure And epilepsy.
• Degenerative disease of brain.

➢ Procedure :-
L.P Needle – 16 G
Adults - 22 G
Child - 25 G
Manometer
Betadine
Spirit
Spinal puncture set

➢ Site :-
L3- L4 in adults
L4- L5 in infant 7 child

➢ Position :-
• Fetal attitude position.
• C shaped in lateral position.

-
 • Sitting position chin fixed on chest.
• Knee chest position (Rarely).

➢ C.S.F Pressure :-
Normal – 5 -15 mm/hg [AIIMS Delhi 2011]
10 -15 CMH2o In lying position.
Standing
30 CMH2O in upright

Sitting position

➢ Quantity :-
6 – 10ml
In each vial 3 ml.

Cytological Historical Other

3 ml 3 ml 3 ml
C.S.F
Component Normal Abnormal value indicate
1. Color Cystal /watery color
Colorless -Turbid/ cloudy – bacterial
infection
2. R.B.C Absent -Present – Internal bleeding
3. W.B.C - 0.5 MM3 -Increase viral infection
- 60 -70% lymphocyte Bacterial
- 30% Monocyte & Macrophage >500/MM3 – Bacterial
- 2% other cells <500/MM3 – T.B.
4. Sugar 40 -60 mg/dl -Decrease in fungal infection &
bacterial infection.
-Increase – D.M, Viral
5. Protein 30 -50 mg/dl -Increase in tumor & bacterial.
6. Chloride level 720 -750 mg/dl -Increase - Uremia
-Decrease - Bacterial infection
7. PH 7.33
Neutrophiles increase in phylogenic infection .

➢ Storage :- 4oC
At room temperature – 1 Hours.
➢ Complication :-
• Most common headache( Due to leak of fluid in near by tissue)
 • Brain herniation dangerous.
• Infection
• Bleeding
➢ Care after Lumber Puncture :-
1. Give flat supine position after L.P.
2. Give plenty of food .
3. Give Coffee, Tea, Sodas having caffeine because Caffeine reduce headache.
4. Give rest.
Go emergency department or inform the doctor if-
a. Having sever headache & persistent.
b. Having Fever, Stiff neck,
c. Bleeding
d. Numbness on leg.
Blood Transfusion
➢ Components :-
A. Packed RBC –
• 1 Unit bag = 250 ml.
• Each unit increase 1 gm/dl or 2 -3% Hematocrit increase.
• Laboratory value change in 4 to 6 hrs.
B. Whole Blood –
• 1 unit = 400 ml ( 350 ml [Blood] + 50 ml [Preservative CDPA] )
C - Citrate (Anticoagulant)
D - Dextrose
P - Phosphate
A - Adenin
C. Platelets :-
• Platelets to treat thrombocytopenia.
• 1 unit bag = 50 -70 ml to 200- 400 ml.
• 1 unit increase 5000 to 10000 cell/mm3.
• Rapid Transfusion – 15 to 30 min.

D. Fresh Frozen plasma –

• It provide clotting factor & act as a volume expender.
• Rapid transfusion – 15 -30 min.
• It should be infuse within 2 hrs of melting.

E. Cryoprecipitate :-
- Factor VIII & Fibrogen prepare from fresh frozen plasma.

Components Storage Temperature Storage Time

Whole Blood 2 -6o C 33 days
RBC 2 -6o C 35 -42 days

-
 Platelets 22o C 5 days
WBC 2 -8o C Same day infused
FFP/Cryoprecipitate 20 to 40o C 1 year.

➢ Blood Donation Criteria :-

• Age -- 18 -65 years.
• Weight -- Above 48 Kg.
• Donate once in 3 months.
• HIV, Hepatitis, Malaria, Syphilis & TB patient don’t donate the blood.

o Key Points:-
• 2 Nurses should check the unit bag.
• Before blood transfusion assess vital signs.
• Nurse should stay first 15 minutes with patient.
• 1 Unit blood should be infused within 4 hours. (Ideally 2 hours.)
• B.T. set should be changed after 4 to 6 hours.
• Use 0.9% NS before blood transfusion to prevent Hemolysis.

➢ Complication of Blood Transfusion:-

1. Transfusion Reaction:-
Chills, Diaphoresis, Rashes, Itching, Swelling, Rapid thready
pulse, Dyspnea, Wheezing, Chest pain, Body pain, Muscle ache.

Intervention –

• Stop transfusion.
• Start 0.9% NS (To open vein )
• Notify to physician.
• Return blood bag to blood bank.

2. Circulatory Overload :-
- Dyspnea - Hypertension - Bounding pulse
- Cough - Headache - Distended neck vein
- Chest pain - Tachycardia

Intervention –

• Slow rate of infusion.

 • Upright position.
• Notify physician.

3. Septicemia: -
- Chills - Diarrhea
- Fever - BP decrease
- Vomiting - Septic shock

Intervention –

• Stop the transfusion.

• Notify the doctor.

4. Iron Overload:-
Delayed reaction.

Antidote – Deferoxamine.

5. Hypocalcaemia:-
It is due to excessive citrate.

Intervention –

• Slow transfusion.
• To notify health care provider.
6. Hyperkalemia: -
The stored blood liberates K+.

Intervention –

• Slow transfusion.
• To notify the HCP.

7. Disease Transmission: -
Hepatitis – C (Post transfusion disease)

8. Citrate Toxicity: -
Cause Hypocalcemia & hypomagnesemia.

Intervention –

• Stop transfusion.
• Notify HCP.
 Suture Material
The thread, wire, or other material used to stitch parts of the body together called suture.

➢ Types :-
A. Non Absorbable :-
• A suture made from a material that is not absorbed by the body, such as silk, polymers,
cotton or wire.
i. Nylon wire (ethilon) –
o Monofilament polyamide.
o Use for anastomosis of small blood vessels and skin.
o Removal time of suture-
▪ On scalp & face – 5 to 7 days.
▪ On upper limb & abdomen wound – 7 to 10 days.
▪ On lower limb – 10 to 14 days.
ii. Proline –
o Monofilament polypropylene blue.
o High tensile strength.
o Use repairs of muscles, big blood vessels, tendon, ligaments and
peritoneal sheath.
iii. Silk suture –
o A suture made of silk.
o It may be twisted, braided, or floss.
o Used on skin or on soft tissue of body & ligature of blood vessels.
iv. Barber thread –
o Cotton threads use for ligation.
B. Absorbable Surgical suture –
• a sterile strand prepared from collagen fibers derived form healthy mammals or from a
synthetic polymer.
• This type of suture is absorbed and thus does not need to be removed.

-
 i. Catgut suture –
o A suture material made from the sterilized sub-mucosa of the small
intestine of sheep.
o It is eventually absorbed by body fluids.
o Plain catgut - Absorption time is a 5 to 10, so use in surgery of intestine
and soft tissue.
o Chromic catgut – Catgut coated by chromium trioxide to
o increase absorption duration (10 to 40 days.)

ii. Vicryl (Braided) –

o Poly glycolic acid or poly galectin acid with triclosan (antibacterial
coating.)
o Use in soft tissues.
o Normal absorption time 56 days, abdomen completely absorption time 90
days.
iii. PDS (Monofilament polydioxanone violet) –
o Used in soft & hard tissue.
o Absorption time in 96 days.
iv. Monocryl -
o Monofilament.
o Used in soft tissues.
o Absorption time is 15 -30 days.
➢ Needle –
A pointed instrument for stitching, ligaturing, puncturing or cannulating.

Types of Needles –

o Straight or curved
o Cutting or round needle.
▪ Cutting edge needles are used in skin and dense tissue.
▪ Round point needles are used for more delicate operations, especially on
soft tissues.
o Traumatic ( Eye present ) Or atraumatic (Non eye).
o Scalp vein needle – A specially designed needle for the administration of
intravenous fluids.

o Suture Removal technique - Remove Sutures always after secure intermittently incision line.

Wound
Dehiscence - when wound edges separate. If abdominal organ protrude out thorough the gap of
wound. It is known as evisceration if wound is infections clean center to peripheral.

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 ➢ Wound healing process :-
i. Inflammatory Phase (24 -48 hours)
ii. Proliferative phase (3 -5 days)
iii. Fibro plastic phase (4th day to till 2 -4 week.)
iv. Maturation phase (3rd week to One year.)
➢ Types of Dressing :-

1. Non-antiseptic dressing – Sterile non medicated dressing applies to a fresh wound.

2. Antiseptic dressing - Impregnated with some medications are applied to wound already
infected.
3. Wet dressing - Used in infected wound to soften the discharge, promote drainage,
supply heat to the tissue.

Traction & Extension

Used to restore an injured part for its maximum functioning.

➢ Types of Traction:-
1. Skin traction:-
a) Buck’s extension: -
• Achieved by clinging wide bands of adhesive directly to the skin & applying
weights to these bands.
• Buck’s extension, Bryant’s traction & Russell traction are the three most
commonform of skin traction used in injury to the lower extremities.

b) Bryant’s Traction (Gallow’s Traction) :-

• Applied to both limbs can be used to reduce fracture of the femur in children
under 6 years.
• Both legs are suspended vertically with the hip flexed at 90o & the knees are
extended.

c) Russell’s Traction: -
• Used in the treatment of fracture of the shaft of the femur.
• It creates a forward & upwards pulls on the leg by applying vertical traction at the
knee.

2. Skeletal traction :-

Halo traction

Head halter traction

• Accomplished by introducing a metal wire (Kitschier wire) or metal pins

(Steinmann pins) or metal tongue (crush field tongue used in skull traction)

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 • Dunlop traction for supra condyles humerus fracture in children.
• Halo traction and head halter are skeletal traction for cervical vertebrae and
spinal cord injury.
• Head is elevated in all skull traction.

Irrigation and Instillation

• Irrigation – washing or flushing of an area.
• Instillation- Process which a liquid (Medication) is introduce in to a cavity drop by drop.

➢ Eye irrigation:- Washing conjunctive sac.

• Solution used – Boric acid used as anti septic,
• Plain water – as cleansing agent.
• As drug instillation solution – adrenaline 1/10000 to check bleeding.
• Silver nitrate 1% - in gonococcus as antiseptic.
• Atropine 1% - (Midrate) to dilate the pupil.
• Cserin 1 -2% (myotic) – to contract the pupil.
• Position - Supine and head tilt to the affected side.
• Direct the flow of fluid from the inner can thus to the outer can thus to prevent forcing
the infection into the nasolacrimal.
• Solution always used as body temperature.
• Nozzle dropper should above then 2 cm from eye.

➢ Ear irrigation :-
- Washing the external auditory canal.
Purpose – Remove wax (cerumen) and to evaluate vestibular function (biothermal
calorictest)

Stool Specimen
• Dark brown in color.
• Pungent Smell.
• Meconium- First Stool or New born (Dark Green)
• Tarry black stool – Indicate bleeding in the upper GIT.

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 • Melena – Black color stool
• Clay color stool – obstruction to the flow of bile.
• White stool may appear due to barium meal.
• Rice water stool - in Cholera.
• Ribbon like stool- in Hirschsprung’s disease.
• The commonest cause of blood & mucus found in the stool is due to dysentery which may be
amoebic or bacillary.
• Jelly like stool – Intussusception.

Sputum specimen
• Normally no sputum is expected.
• Sputum is odorless.
• yellowish Sputum = due to pus.
• Black sputum = Contain a lot of Carbon atoms seen in smoking condition.
• Hemoptysis = presence of blood in sputum.
• Rusty color of Sputum = Pneumonia.
• Greenish color Sputum = Bronchiectasis. (Dilation bronchi and bronchiole)
• Brown color sputum = Gangrenous Condition of lungs.
• In Asthma sputum contains Eosinophils.
• The Sputum should be collected in the morning before brushing the teeth & food.
• Mouth can be rinsed and plain water & not with antiseptic mouth wash.

Restraints
These are protective devices employed to prevent a client from hanging himself or others to immobilize
a part, to restrict the activity.

➢ Types :-
Restrain are made up of linen, Canvas, leather, plastic metal or wood.

1. Ankle & Wrist :- (Clove hitch Restrain)

Used to restrict the activity of limbs in a client who is potentially harmful to himself or
others. Uses in IV infusion in child or immobilized the arm and leg.

2. Elbow & Knee Restrain:-

Used to prevent flexion of the elbow & knee joint. (Used after the operation of head,
faceor to safe naso gastric tube.)

3. Mitt Restraints:-
Used for children or confused patient in order to prevent using their fingers or hands for
removing tubes.

4. Body Jackets:-
- Used for both children & Adult.
- The jacket is usually put on back.
5. Mummy Restrain:-
Used to restrain the movement of the limbs in a small child during a procedure (during
an eye irrigation, ENT examination, scalp vein puncture)

6. Safety Belts:-

- Made up of electronic non-conductive material.

- Used on stretchers & operation table in order to prevent the client from
falling.
 Gaits/Points
- Manner of walking with crutches.

• There are five Gaits commonly used in crush walking.

1. Four-point Gaits –
- Right crush forward
- Left foot forward
- Left crutch forward
- Right foot forward

2. 3-point Gaits – (orthopedic Gait)

▪ Used when complete weight bearing is allowed on one foot and partial or no weight
bearing is allowed on the other foot.
▪ Both crutches & the non-weight bearing foot are placed forward.
▪ Weight bearing foot are placed forward.

3. 2-point Gaits –
▪ Gait similar to walking.
▪ Weight bearing is permitted equally on both feet.
▪ Left crutch & Right foot are placed forward.
▪ Right crutch & the left foot are placed forward.
4. Swing to crutch Gait-
▪ Crutches are placed ahead of the client & the client than swings forward to the crutches.

5. Swing through crutch Gait –

▪ Both crutches are placed ahead of the client & the client then swing through the crutches
& advances to a position in front of the crutches.
▪ Crutch of length = Height of Person – 16 inches.
 Legal & Ethical Aspect
➢ Legal Aspect: -
Tort - A civil wrong made against a person or property intentionally or
unintesion.
➢ Types of Tort: -
1. Intension Tort –
• Assault
• Battery
• Invasion of privacy
• Defamation of character
• False imprisonment
A. Assault: -
Intentional threat to bring about harmful & offensive contact.
B. Battery: -
Intentional touching to patient without their consent (Physical contact)
C. Invasion of privacy: -
It includes violating confidentiality on private client or family matter and sharing patient
information with unauthorized person.
D. Defamation of Character: -
Publication of false statement that result in damage to a person reputation.
- Malice – Person publish information knows it is false.
- Slander – It is statement made orally.
- Libel - If the statement made in writing.
E. False imprisonment: -
it occurs when the patient is not allowed to leave the health care facility when there is no
justification to detain or restraining is used without appropriate clinical need.

2. Unintentional Tort: -

A. Negligence: -
It is a conduct that falls below standard care or lack of proper care or Carelessness.
B. Malpractice: -
Failure in Professional duty, skill, Practice that lead to injury or harm to patient.
- It is a type of Negligence.
➢ Informed Consent: -
Client’s approval / person’s agreement to do something.
➢ Contract- A written or orally agreement between two people in which goods & services are
exchange

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Professional Bodies

1) INC [Indian Nursing Council]:-

• INC act 1947.
• Establish in 1949.
➢ Purpose-
- To maintain uniform standard of the Nursing education.
- Reciprocity in nursing registration throughout India.
2) TNAI [Trained Nurses Association of India] –
• Establish in 1922.
• First Professional organization in India.
• Head Quarter in Delhi.
• TNA establish in 1909.
➢ Publication - Nursing Journal (monthly)

3) SNA [Student Nurses Association] –

• Establish in 1929.
• Subunit of TNAI.
4) ICN [International Council of Nurses] –
• Mr. Bedford Fenwick.
• Establish in 1899.
• Head Quarter in Jenewa.

➢ Code of Ethics:- 1953, Sao Paulo Brazil

• In India adopted in 1973 by INC.
• Nursing Review - Every 4 month.
• New latter - 10 times in 1 year.

RNC [Rajasthan Nursing Council]-

It was established under Rajasthan Nursing midwives, health visitor & Auxiliary Nurse
midwives Registration Act No. – 9, 1964
Publish – 28/03/1964

➢ Common Wealth Nursing Association: -

• Establish in 1973.
• Head quarter in London.

➢ Christian medial Association of India: -

• Establish in 1905.
• Active word in the South.
• Set up in Bangalore.
• In this doctor are included.

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 ➢ The Nurses league of Christian medical association :-
• Establish in 1930.
• Only for Christian Nurses.
- American Nursing Association – 1911
- Health Visitor league – 1927
- Midwives & ANM Association - 1925

“Ethical Aspects in Nursing”

Ethics means the rules & regulations that govern right behavior (Conduct).

➢ Code of Ethics: -
• Given by ICN in 1953 (Sao Paulo Brazil)
• In India adopted in 1973 by INC.
• The code of ethics state what kind of conduct is expected.
➢ Aspect of Code of Ethics: -

A. Nurse & People :-

• Primary responsibility is the patient who require care.
• Give respects to, Customs, Spiritual, belief & value.
• Confidentiality

B. Nurse & Practice: -

Provide standard care & Nurse standard conduct.

C. Nurse & Society: -

Sharing the responsibility with society to meet health & Social need.

Nurse & Profession: -

Improved care with professional knowledge & participates in establishing & maintaining
equitable social & economical working condition in Nursing.

E. Nurse & Co-Worker: -

Maintain Co-operative relationship.

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