LESSION PLAN

NAME OF SUPERVISOR : Mrs. Sapana Thakur

NAME OF STUDENT : Mrs. Bersila Prakash

SUBJECT : Nursing Education

TOPIC : vital signs & cold spoging

CLASS : M.Sc (N) Previous.

DATE : 20/12/10

TIME : 3-4 PM.

MEDIUM : English

MODE OF TEACHING : Demonstration

A.V AIDS : Articles, Blackboard,LCD

 GENERAL OBJECTIVE : to make the students understand the procedure of vital
signs & cold sponging & to demonstrate it effectively.

SPECIFIC OBJECTIVE : At the end of class student will able to -:

o To enlist types of fever, pulse, & respiration.
o To ascertain the advantages & disadvantages of different sites of taking
temperature.
o To describe the different types of thermometer
o To demonstrate oral temperature, pulse & respiration.
o To demonstrate axilla & rectal temperature
o To demonstrate the procedure of blood pressure.
o To demonstrate the procedure of cold sponging
S, TIME specific CONTENT TEACHING A.V AIDS EVALUATION
no. OBJECTIVE –LEARNING
ACTIVITY
1 2 min. To introduce INTRODUCTION-: Lecture cum Articles Questionnaire
the topic The body integument is a Demonstration
protective barrier against disease
causing organism & a sensory organ
for pain, temperature, touch &
pressure. Injury to the skin is a great
risk to safety & it sets off a complex
healing response. The skin has two
layers the epidermis & the dermis is
the outer layer & is composed of
stratified epithelium. & the dermis is
inner layer is to tough & elastic. It is
composed of collagen fibers with
elastic fibers.

2 5 min. To define the DEFINITION-: Lecture cum Articles

definition of Demonstration
wound 1.A wound is a break or cut in the
continuity of any body structure
internal or external caused by
physical means.
2.A wound is an injury in which the
skin is cut or penetrated.
3.A wound is a break in the surface
epithelium. This may be either:
 a. Intentional.
b. Accidental.

3 5 min. To describe PURPOSE OF WOUND Lecture cum Articles

the purpose. DRESSING:- Demonstration
 To prevent infection.
 To prevent further tissue
damage.
 To promote healing.
 To absorb inflammatory exudate
& to promote drainages.
 To convert the contaminate
wound into a clean wound.
 To restore the function of the
part.
 To protect the wounds from
contamination with microorganism.
 To provide maintenance of high
humidity between the wound &
dressing.
 To promote thermal insulation to
the wound surface.
  To provide mental & physical
comfort for the client.

4 6 min. To explain the CLASSIFICATION Lecture cum Articles

classification ACCORDING TO TYPE OF demonstration.
of wound . INJURY:-
Abrasion:- It is a superficial wound
produced by friction or scraping.
Laceration:- It is tearing of tissues,
which occurs with irregular wound
edges.
E.G- from animal bites, machinery
cut or tissues cut by broken glass.
Contusion:- It is a closed wound
caused by a blow to body by some
blunt object. It is characterized by
swelling, discoloration & pain.
Puncture (stab):- It is a wound
made with a pointed object such as
nail, wire or bullet that pierces
deeper tissues.
Penetrating wound:- It occurs as a
result of an instrument, passing
through skin or mucous membrane
to deeper tissues & entering a body
cavity or organ.
Perforating wound:-It is caused by
an instrument that both enters &
energes from a body cavity or organ.
A gunshot wound may perforating or
penetrating.
CLASSIFICATIONACCORDING
TO CONTINUITY OF SURFACE
AREA:

Open wound: These are the wound

involving a break down in skin or
mucous membrane. Their cause is
trauma by sharp object or blow e.g-
gun short wound.

Closed wound : These wound are

involving no break in skin integrity.
Their cause are twisting, staining
bone fracture or tear of visceral
organ.
CLASSIFICATIONACCORDING
TO CAUSE:

Intentional: Example of such

wound are surgical incised wound,
stab wounds.
 Accidental wounds : Such wound
occurred under unexpected
conditions. Example traumatic
injury & knife wound
5 4min To enlist the INDICATION OF WOUND Lecture cum Articles
indication of DRESSING:- demonstration
wound  Pressure ulcer. .
dressing.
 Skin tears
 Contact dermatitis
 Psoriasis vulgaris
 Diabetic foot.

GUDIELINES FOR WOUND Lecture cum Articles

6. 6 min. To describe the DRESSING: demonstration
guideline for 1 The nurse should perform
wound thorough hand – washing before &
dressing after dressing.
 2 Practice strict a septic techniques
to reduce transmission of micro-
organism.
3 All articles, touching the wound,
should be sterile.
4 if soakage is present, dressing
should be changed frequently.
5 Separate instruments should be
used for each dressing.
6 Cleaning of the wound should be
done from the cleanest area to the
less clean area, center to periphery .
7 Saline should be used to remove
adherent dressing.
8 Drainage from the wound should
be measured, notified & recorded.
9 Drains should be shortened or
remove according to doctor’s
advice.
10 Medicine are given & applied by
only according to doctor’s.
11 Economy is to be observed in the
use of materials, & time spent.

7 10 min. To tell about Articles Purpose Lecture cum Articles

the preparation demonstration
of the articles A Sterile tray
Containing:
1Artery forceps To clean the wound
I.
2 Dissecting
Forceps-2.
3Sterile gloves To maintain asepsis
4 Scissor-1 For the debridement
Of wounds & to cut
Gauze to pieces
5 Sinus forceps To help in drainage
1 of sinus.
6 Probe -1 To open the sinus
Tract.
7 Small bowl-1 To take the clean
-ing solution
8 Safety pin-1 To fix the drain,
In case the
Drains are cut
Short
9 Gloves, mask& To use when
gown large wound
dressed.
10 Cotton balls, To clean &
Gauze pieces dress the
Cotton pads etc. wound
necessary

BUNSTERILE TRAY
CONTAINING :
1 Cleaning solution To clean the
As necessary wound & the
 Surrounding
Skin area.
2 Ointment & To apply on
Powders as the wound
ordered
3 Vaseline To prevent
Gauze in sterile the dressing
containers adhering to
the wound
4 Ribbon gauze To pack a
In sterile containers sinus tract
Or a penetra
-ting wound
5 Swab stick in To apply
A sterile container the medica
-tion if
Necessary
6 Transfer forceps To handle
In a sterile container the sterile
Supplies
7 Bandages, binder To fix the
Pins, adhesive, plaster dressing
7 scissors in place
8 A large bowel To discard
With disinfectant the used
solution instruments.
9 Kidney tray To collect
& paper bag the waste
10 Mackintosh To protect
 & towel the bed
Linen.

8 2 min. To explain PRELIMINARY ASSESSMENT: Lecture cum Articles

about 1Check the diagnosis & the general demonstration
preliminary condition of the client.
assessment 2 Check the purpose of which the
dressing is to be done.
3 Check the condition of the wound
the type of the wound, the types of
suturing applied, the types of
dressing to be applied etc.
4 Check the physician’s order for the
type of the dressing to be applied &
the specific instruction, if any,
regarding the cleaning solution,
removal of sutures, drains & the
application of medications etc.
5 Check the client’s name, bed
number & other identification.
6 Check the abilities & limitation of
the client.
7 Check the consciousness of the
client & the ability to follow
instruction.
8 Check the nurse’s records to find
 out the general condition of the
wound.
9 Check the articles available in the
unit.

9 5 min To tell about PREPARATION OF THE

the preparation CLIENT :
of the client 1Identify the client & explain the
procedure to win confidence & co-
operation. Explain the sequence of
the procedure & tell the client how
he can co-operate in the procedure.
2 Provide privacy with curtains &
drapes.
3 Apply restraints, in case of
children.
4 As far as possible , avoid meal
timing , the dressing may be done
either one hour before the meals or
after meals .
5 Offer bed pan & urinal prior to the
dressing.
6 Give some analgesic if the client is
in pain, eg before dressing extensive
burned wounds.
7 See that the cleaning of the room is
done at least one hour before the
expected time of dressing.
8 Shave the area if necessary to
remove the hair . Removal of
adhesive is very painful if the hair is
present. So the shaving should be
done before the first dressing
applied.
9 Place the client in comfortable &
relaxed position depending on the
area to be dressed.
10 Give proper support to the body
part if the client has to raise & hold it
in position for a consideration time.
11 Close the window & door to
prevent drafts & also put off the fan.
12 Adjust the bed height for the
comfortable working of the doctor or
nurse so that they have neither to
stoop nor over reach to do the
dressing. Bring the client to the edge
of the bed.
13 Call for the assistance if
necessary eg. To do unsterile
procedure to transfer sterile supplies
etc.
14 protect the bed with mackintosh
& towel.
15 Turn the head of the client at one
 side , so that the client may not able
to see the wound and get worried.

10 10 min To explain the Steps of Rationale

steps of procedure
procedure 1 Identify the
client first.
2 Inform the Encourage client &
client about for client co
the procedure operation.
what you are
going to do.
3 Gather An organized
equipment & approach save time
arranged at & energy.
the bed side.
4 Wash hands. To reduced speared
of micro organism.

5 Check the Clarifies types of

physician dressing.
order for
dressing
changing &
any specific
instruction.
6 Close door Provide privacy &
& curtains & soiling of the bed
place water linen.
proof pad on
bed beneath
the area of
dressing.
7 Assist client Provide comfort for
to comfortable client.
position that
provide to
easy access to
wound area.
8 Place open, Reduced risk of the
cuffed plastic contamination from
bag near soiled dressing &
working area. used cotton balls.
9 Loosen Removal of tape is
tapes on easier before
dressing ( if wearing the gloves.
tape is soiled ,
wear clean
gloves before
loosening the
tape) .
10 Don clean Protect the nurse
gloves & from contamination.
remove soiled
dressing
carefully from
more clean to
less clean
area.
11 Keep Caution removal of
soiled side dressing is less
dressing away painful for the
from the client.
client’s view.
12 Discard Prevent spread of
dressing in micro – organism.
disposable
bag, pull of
gloves inside
out & discard
in appropriate
receptacle.
13 Using To keep supplies
sterile within easy reach &
technique, maintain sterility.
open dressing
tray &
arranged
supplied on
work area .
14 Open
cleaning
solution &
pour into the
sterile
gallipots/ cup
over cotton
ball.
15 Don sterile Maintain asepsis.
gloves.
16 Pickup the
soaked cotton
using , artery
or forceps.
17 A For a Moving from least
surgical to more
wound , clean contaminated area to
from top to spread of micro-
bottom or organism to less
from center infected area.
out ward.&
contaminated
wound clean
from
periphery to
center.
B Use one
cotton swab /
gauze sponge
for each
wipe ,
discarding
each by
dropping into
the plastic bag
after wiping
do not touch
the plastic bag
with forceps.
C If a drain is
present, clean
around it
moving from
center out
ward in a
circular
motion . Moisture provide
D Dry the medium for growth
wound using of micro- organism
sponge in a & drying prevent
same motion. that growth &
improve healing.
Additional dressing
18 Apply serves as a wick for
medication drainage.
ordered to the
wound on a
dry sterile
gauze , apply
a layer of
sterile
dressing over
wound . Drainage is
19 Place a absorbed &
sterile gauze surrounding skin
slit on side area is protected.
under &
around the
drain ( use pre
cut gauze or
cut one using
sterile
scissors) Provided for
20 Apply a absorption of wound
second layer drain & protection
of gauze to from micro-
wound site & organism.
a surgical pad
as the
outermost
layer.
21 Remove
gloves inside
out & discard
in plastic
waste
bag .Apply
adhesive tape
to secure the
dressing. Prevent spread of
22 Wash the infection.
reusable
 articles to be
send for
sterilization. Prevent spread of
23 Wash infection.
hands &
remove all
articles &
make client’s
comfortable. Provide accurate
24 Record documentation of
dressing procedure.
change
appearance of
wound &
describe any
drainage in
the chart.

AFTER CARE OF THE CLIENT’S AND THE ARTICLES:

1. Help the client to dress up properly & to take a comfortable position in the bed change the garment if
soiled with drainage.
2. Replace the bed linen.
3. Remove the mackintosh and towel .
4. Take all articles to the utility room . Discard the soiled dressing into a covered container and send for
incineration . Remove the instruments and other articles from the disinfected solution and clean them
thoroughly. Dry them re set the tray and send for autoclaving . Replace to all other articles to there proper
places. Send the soiled linen to the laundry bag for washing ( remove the blood stains before sending to
dhobi.
5. Wash hands .
6. Record the procedure on the nurse record with date and time . Record the condition of the wound , the
type and amount of drainage , condition of the sutures etc on the nurse record. Report to the surgeon any
abnormality found.
7. Returned to the bed side to assess the comfort of the client special instruction in the care of the wound
are to be communicated to the client.
8. Tidy up the unit of the client and the bed.