Advanced Nursing Handout

TABLE OF CONTENT
CHAPTER ONE
Dressing, removal of stitches and clips,
Care of the colostomy bag, wound swabbing and care of the drainage tube
CHAPTER TWO
IV therapy, blood transfusion, parental, nutrition and intake and output
CHAPTER THREE
Chest aspiration, bronchoscopy, bronchography, cardiac catherization,
Care of the patient with tracheostomy tube, sunctioning and postural drainage, under seal water
drainage, E. C. G, Echocardiography.
CHAPTER FOUR
Barium meal, barium swallow, barium enema, endoscopy, proctoscopy, laparoscopy
Liver biopsy and abdominal paracentesis
CHAPTER FIVE
Passing of NG tube, feeding through the NG tube, gastrostomy feeding,
Fractional test meal, stomach wash out and feeding of special patients, colostomy and ileustomy
CHAPTER SIX
Collection of specimen, 24hour urine collection, mid-stream urine collection,
Intravenous pyelography, retrograde pyelography, cystoscopy and peritoneal dialysis
CHAPTER SEVEN
High vaginal swab, salpingography, pap’s smear, breast examination, urethral catheters,
Catheterization, catheter hygiene
CHAPTER EIGHT
Penile swab, catheterization of the male patient, bladder training, bladder irrigation
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CHAPTER NINE
Nursing management of patient with orthopedics disorders, pre and post op,
Skin and skeletal tractions, and management of a patient with POP
CHAPTER TEN
Lumbar puncture, bone marrow aspiration, electroencephalography
CT scan of the brain, nursing of special patients and Radiotherapy
CHAPTER ELEVEN
Pre and post op care of patients with eye problems, eye irrigation,
Eye swab and administering eye medications
CHAPTER TWELVE
Nursing care of patient with ENT conditions, pre and post op, nasal swab,
Post nasal swab, nasal drop and instillation, antrum wash-out,
Taking a throat swab, gargling, ear swab, ear drops, ear irrigation and painting of the throat.
CHAPTER ONE
WOUND DRESSING
Objectives
 To be able to describe the principles of wound healing.
 Recommend appropriate wound care and follow-up.
THE SKIN
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Figure 1-1 Diagram of the skin
FUNCTIONS OF THE SKIN
 Regulates body temperature.
 Prevents loss of essential body fluids, and penetration of toxic substances.
 Protection of the body from harmful effects of the sun and radiation.
 Excretes toxic substances with sweat (waste removal).
 Mechanical support.
 Immunological function mediated by Langerhans cells.
 Sensory organ for touch, heat, cold, socio-sexual and emotional sensations.
 Vitamin D synthesis from its precursors under the effect of sunlight and introversion of
steroids.
WOUND-DEFINITIONS
A wound is the loss of continuity of the skin or mucous membrane which may involve soft
tissues, muscles, bone and other anatomical structure. It can also be defined as any disruption to
layers of the skin and underlying tissues due to multiple causes including trauma, surgery, or a
specific disease state.
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Any break in the continuity of body tissue
Examples: grazes, burns, surgical incisions, stabs, leg ulcers, decubitus ulcers (pressure sores)
WOUND HEALING
There are various types of wounds according to intended classification. These could influence
the expected healing process it should go through. The types of wounds are:
Intentional – results from planned treatment such as IV/surgery. The wound edges are clean;
bleeding is controlled and usually done under sterile conditions. Therefore less risk for infection
and healing facilitated.
Unintentional wounds- results from unexpected trauma…accident/ burns/ shooting. There is

increased risk for infection since wound resulted from an unsterile environment.
Open -skin broken, portal of entry
Closed – trauma from force, skin intact, soft tissue damage, internal injury, possible bleeding
Acute – goes through normal/timely healing process
Chronic – fails to go through normal stages of healing; no timely progress in healing.
Classification of wound healing
(According to the amount of tissue loss)
 Primary intention healing- clean, straight line, edges well approximated with sutures,
rapid healing
 Secondary intention healing- larger wounds with tissue loss, edges not approximated,
heals from the inside out, granulation tissue fills in the wound, longer healing time, larger
scars.
 Tertiary intention healing- delay 3-5 days before injury is sutured, greater access for
pathogens to invade, greater inflammation, more granulation, larger scars.
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Figure 1-2 Diagram of classification of wound healing according to tissue loss.
WOUND HEALING PROCESS
Wound healing usually goes through 3 main phases, these are:
 The inflammatory phase (Initiated immediately after injury and last 3-6 days)
 The Regenerative (Proliferative) phase
 The Maturative phase
THE INFLAMMATORY PHASE
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WOUND HEALING
Histamine Blood Clot
Vasodilation Dry
Neutrophils& Uniting the
Permeabilit
Monocytes wound edges
y
Oedema& -Dilated blood
Engorgement vessels
0-3 days - Microcirculatio
n slow down
Figure 1-3 Diagram of the inflammatory process
This begins immediately after injury. It includes hemostasis (cessation of bleeding) due to
vasoconstriction and platelet aggregation. There is release of histamine, increasing capillary
permeability (plasma leaking) and vasodilation. Also phagocytosis (process when macrophages
engulf microbes and secrete growth factors that promote angiogenesis) stimulates epithelial buds
at the end of injured tissue resulting in increased circulation which sustains the healing process
Inflammatory Response
4 Cardinal Signs/Symptoms
 Pain- nerve ending damage or toxins from bacteria and pressure from edema
 Redness- increased blood flow to the area
 Heat -metabolic activity occurring on the cellular level
 Oedema- phagocytosis and increased blood flow to the area
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THE REGENERATIVE (PROLIFERATIVE) PHASE
Blood vessels near the edge Begins 2-3 days of injury

of the wound become porous Lasting up to 2-3 weeks
Allowing excess - Resultant tissue filling is referred

moisture to escape To as granulation tissue
- process of wound contraction begins
Macrophage
activity Traps other blood cells &
damaged blood vessels
Stimulates Begin to regenerate within
Formation& the wound margins
multiplication This fibrous
Which
of fibroblasts network
- Laying down of a ground
substance
migrate along - Beginning the synthesis
fibrin threads of collagen fibers
(granulation tissue )
Figure 1-4 Diagram of the regenerative process
Proliferation (Fibroplasia) Phase - second phase, fibroblasts synthesize collagens which add
strength to the wound. Begins 2-3 days after injury. Thin layer of epithelial cells forms, blood
flow is reinstituted. Tissue forms - known as granulation tissue. Translucent red
color/fragile/bleeds easily. Capillaries grow across, fibroblasts form fibrin, collagen continues to
form and white blood cells leave the site. A primary intention wound will be sealed within 24-48
hrs.
THE MATURATIVE PHASE
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Maturation (Remodeling) Phase- final phase begins about 3 weeks after the injury and can
extend up to 6 months up to one or two years after the injury. Fibroblasts continue to synthesize
collagen and the collagen fibers recognized into a more orderly structure. The scar becomes a
thin, less elastic, white line. Collagen originally in haphazard order remodels and reorganizes
into more orderly structure. Scar (cicatrix) forms - avascular tissue, does not sweat, grow hair, or
tan. Keloid- abnormal amount of collagen lay down, hypertrophic scar (Common in dark skin).
CRITICAL WOUND HEALING PERIODS
Tissue
Skin 5-7 days
Mucosa 5-7 days
Subcutaneous 7-14 days
Peritoneum 7-14 days
Fascia 14-28 days
0 5 7 14 21 28
Figure 1-5 Diagram of the critical healing periods
MODEL OF WOUND HEALING
(1) Hemostasis: within minutes post-injury, platelets aggregate at the injury site to form a fibrin
clot.
(2) Inflammatory: bacteria and debris are phagocytosed and removed, and factors are released
that cause the migration and division of cells involved in the proliferative phase.
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(3) Proliferative: angiogenesis, collagen deposition, granulation tissue formation,
epithelialization and wound contraction.
(4) Remodeling: collagen is remodeled and realigned along tension lines and cells that are no
longer needed are removed by apoptosis.
Figure 1-6 Diagram of the phases of wound healing
WOUND HEALING CONCEPTS
 Patient factors
 Wound classification
 Mechanism of injury
 Tetanus/antibiotics/local anesthetics
 Surgical principles and wound prep
 Suture/needle/stitch choice
 Management/care/follow-up
COMMON PATIENT FACTORS
 Age
 Blood supply to the area
 Nutritional status
 Tissue quality
 Revision/infection
 Compliance
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 Weight
 Dehydration
 Chronic disease
 Immune response
 Radiation therapy
Factors Influencing Wound Healing
 Good blood supply: ( oxygen, nutrients)
 Good nutrition:
 Rest: skin cells multiply more rapidly during sleep
 Lack of stress: increased levels of adrenaline and steriods delay healing
 Lack of infection:
 Age : children heal more rapidly than older people
 Site of wound: face and neck heal more rapidly
General factors
 poor diet
 anaemia
 pulmonary disease
 cardiac insufficiency
 arteriosclerosis
 diabetes mellitus
 smoking
 Jaundice
 malignant disease
 high blood urea
 stress
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 lack of sleep
 drug therapy e.g. steroids and cytotoxic
 radiotherapy
Local to patient/wound
 skin edges not lined up
 dead tissue in wound
 foreign bodies in wound
 tension on wound
 infection
 irritant material for suturing
 too tight suturing
Risk Factors Which Increase Patient Susceptibility to infection (Manley. K, Bellman. L,

2000)
A- Intrinsic risk factors:
1. Extremes age: Defined as “Children aged 1 year and under, and people aged 65 years and
over’.
2. Underling Conditions/Disorders
A. Diabetes
B. Respiratory disorders
C. Blood disorders
3. Smoking
4. Nutrition and build
B- Extrinsic risk factors:
1. Drug therapy as a risk factor: e.g. Cytotoxic drugs

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2. Break in the integrity of the skin
3. Items such as foreign bodies
4. Bypassing of defense mechanisms through devices e.g. Intubations
CENTER OF DISEASE CONTROL, (USA) SURGICAL WOUND CLASSIFICATION
This classification scheme has been shown in numerous studies to predict the relative probability
that a wound will become infected. Clean wounds have a 1%-5% risk of infection; clean-
contaminated, 3%-11%; contaminated, 10%-17%; and dirty, over 27% (2, 3, 7). These infection
rates were affected by many appropriate prevention measures taken during the studies, such as
use of prophylactic antimicrobials, and would have been higher if no prevention measures had
been taken.
Clean: (1-5% risk of infection) uninfected operative wounds in which no inflammation is

encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered.
In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage.
Operative incisional wounds that follow non-penetrating (blunt) trauma should be included in
this category if they meet the criteria.
Clean-contaminated: (3-11% risk) operative wounds in which the respiratory, alimentary,

genital, or urinary tract is entered under controlled conditions and without unusual
contamination. Specifically, operations involving the biliary tract, appendix, vagina, and
oropharynx are included in this category, provided no evidence of infection or major break in
technique is encountered.
Contaminated: (10-17% risk) open, fresh, accidental wounds, operations with major breaks in
sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute,
nonpurulent inflammation is encountered.
Dirty or infected: (>27% risk) old traumatic wounds with retained devitalized tissue and those
that involve existing clinical infection or perforated viscera. This definition suggests that the
organisms causing postoperative infection were present in the operative field before the
operation.
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CLASSIFICATION OF SURGICAL WOUNDS ACCORDING TO THE DEGREE OF
CONTAMINATION
Clean wounds: Operations in which a viscus is not opened. This category includes non-
traumatic, uninfected wounds where is no inflammation encountered and no break in technique
has occurred.
Clean-contaminated: A viscus is entered but without spillage of contents. This category

included non- traumatic wounds where a minor break in technique has occurred.
Contaminated: Gross spillage has occurred or a fresh traumatic wound from a relatively clean
source. Acute non-purulent inflammation may also be encountered.
Dirty or infected: Old traumatic wounds from a dirty source, with delayed treatment, devitalised
tissue, clinical infection, faecal contamination or a foreign body.
CLASSIFICATION OF WOUNDS BY DEPTH
I. Partial-thickness: Confined to the skin, the dermis and epidermis.
II. Full-thickness: Involve the dermis, epidermis, subcutaneous tissue, and possibly muscle
and bone
Partial Thickness Full Thickness
Figure 1-7 Diagram of the types of wound according to its depth
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Types of Wound (Hahn, Olsen, Tomaselli, Goldberg, 2004)
Type Cause Description and X’tics
Incision Sharp instrument e.g. Knife Open wound; painful
Contusion Blow from a blunt instrument Close wound, skin appears

ecchymotic (bruised) because
of damaged blood vessels
Abrasion Surface scrape, either unintentional (e.g. Open wound; involving the
scraped knee from fall) or intentional skin ; painful
(e.g. dermal abrasion to remove
pockmarks)
Avulsion Ripping or tearing away part of body parts Open wound; involving all
or tissues (e.g. body part being caught in tissues; painful; may lead to
running machinery) death depending on the part
involved.
Puncture Penetration of the skin and, often the Open wound; can be
underlying tissues from a sharp intentional or unintentional
instrument
Laceration Tissues torn apart, often from accidents Open wound; edges are often
(e.g. machinery) jagged
Penetrating Penetration of the skin and the underlying Open wound; usually
wound tissues accidental ( bullet or metal
fragments)
Table 1-1 Tabulation of the types of wounds
WOUND ASSESSMENT
 A complex process
 Involve examination of the entire wound
 Nurses visually assess wounds and document their findings to monitor and evaluate the
progress of wound healing
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What to assess?
Figure 1-8 Diagram of the assessment of wounds.
1. Location
2. Dimensions/Size
3. Tissue viability
4. Exudate/Drainage
5. Peri-wound condition
6. Pain
7. Stage or extent of tissue damage , dictates how often a wound is

reassessed
8. Swelling
NURSING DIAGNOSES
– Risk for Impaired Skin Integrity
– Impaired Skin Integrity
– Impaired Tissue Integrity
– Risk for Infection
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– Pain
THE RYB COLOR CODE

(STOTTS, 1999)
This concept is based on the color of the open wound rather than the depth or size of the wound.
On this scheme, the goal of wound care is to protect (cover) red, cleanse yellow, and debride
black. The RYB code can be applied to any wound allowed to heal by secondary intention.
Red wounds
Figure 1-9 Picture of a red wound
Usually in the late regeneration phase of tissue repair (i.e., developing granulation tissue) and are
clean and uniformly pink in appearance
They need to be protected to avoid disturbance to regenerating tissue. Examples are superficial
wounds, skin donor sites, and partial- thickness or second – degree burns.
How to protect red wounds:
 Gentle cleansing
 Avoid the use of dry gauze or wet- to-dry saline dressings.
 Applying a topical antimicrobial agent.
 Appling a transparent film or hydrocolloid dressing.
 Changing the dressing as infrequently as possible.
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Yellow wounds
Characterized primarily by liquid to semiliquid”slough” that is often accompanied by purulent

drainage. The nurse cleanses yellow wounds to absorb drainage and remove nonviable tissue.
Figure 1-10 Picture of a yellow wound
Methods used may include:
 Applying wet-to-wet dressing; irrigating the wound; using absorbent dressing

material such as impregnated non-adherent, hydrogel dressing, or other exudate
absorbers; and consulting with the physician about the need for a topical
antimicrobial to minimize bacterial growth.
Black wound
Covered with thick necrotic tissue or Eschar e.g. third degree burns and gangrenous ulcer.
Figure 1-11 Picture a black wound
 Required debridement.
 When the eschar is removed, the wound is treated as yellow, then red.
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PURPOSES OF WOUND DRESSING
1. To protect the wound from mechanical injuries
2. To protect the wound from microbial contamination
3. To provide or maintain high humidity of the wound
4. To provide thermal insulation
5. To absorb drainage and /or debride a wound
6. To prevent hemorrhage (when applied as a pressure dressing or with elastic bandages).
7. To splint or immobilize the wound site and thereby facilitate healing and prevent injury.
8. To provide psychological (aesthetic) comfort.
PRINCIPLES OF ASEPSIS
The aim:
 Guarantee the safety of the equipment used (cleaning/disinfection/sterilisation).
 Reduce the level of microbial contamination of the site requiring manipulation

(antisepsis).
 Ensure that no microorganisms are introduced (asepsis).
Cleaning : Is the removal of dirt, debris and organic material.
Disinfection: Removes or destroys harmful microorganisms but not bacterial spores or slow
viruses.
Sterilization: is the complete destruction or removal of all living microorganisms including

bacterial spores.
Antisepsis: is the reduction of the number of microorganisms already present on the body site
prior to a procedure.
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Asepsis: Procedure designed to prevent any introduction of microorganisms to the site achieved
by a non-touching technique and use of sterile gloves
GUIDELINES FOR CLEANING WOUNDS
1. Use physiologic solution, such as isotonic saline or lactated ringer solution.
2. When possible, warm the solution to body temperature before use.
3. If the wound is grossly contaminated by foreign material, bacteria, slough, or necrotic

tissue clean the wound at every dressing change.
4. If a wound is clean, has little exudate, and reveals healthy granulation tissue, avoid
repeated cleaning.
5. Use gauze squares.
6. Consider cleaning superficial non-infected wound by irrigating them with normal saline
rather than using mechanical means.
7. To retain wound moisture, avoid drying a wound after cleaning it.
TOPICS FOR HOME CARE TEACHING
 Supplies
 Infection prevention
 Wound healing
 Appearance of the skin/recent changes
 Activity/mobility
 Nutrition
 Pain
 Elimination
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COMPLICATIONS OF WOUNDS
 Haemorrhage (surgical wounds) - bleeding some is normal. Excessive bleeding- can be

caused by a dislodged clot, stitch slipped, blood vessel erosion. May see a hematoma-
collection of blood under the skin looks reddish/blue bruise
 Infection bacteria enter becomes infected
 non union
 Rupture (dehiscence) - partial or total rupturing of a sutured wound. MORE COMMON

WITH OBESE INDIVIDUALS
 Pressure and strain (coughing vomiting) can lead to EVISCERATION- protrusion of

internal viscera (internal organs) through the incision.
 over granulation of scar tissue
 contractures
S & S of Presence of Infection
 Wound is swollen.
 Wound is deep red in color.
 Wound feels hot on palpation.
 Drainage is increased and possibly purulent.
 Foul odor may be noted.
 Wound edges may be separated with dehiscence present.
TYPES OF WOUND DRAINAGE
Exudate is material, such as fluid and cells, which has escaped from blood vessels during the
inflammatory process and deposited in or on tissue surfaces. The Nature and amount of exudate
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vary according to: Tissue involved intensity and duration of the inflammation, and the presence
of microorganisms.
1. Serous Exudate
 Mostly serum
 Watery, clear of cells
E.g., fluid in a blister
2. A purulent Exudate
 Is thicker than serous exudate because of the presence of pus.
 It consists of leukocytes, liquefied dead tissue debris, dead and living bacteria.
 The Process of pus formation is referred to as suppuration, and the bacteria that produce
pus are called pyogenic bacteria.
 Purulent exudate vary in color, some acquiring tinges of blue, green, or yellow. The color
may depend on the causative organism.
3. A sanguineous (hemorrhagic) Exudate
 It consists of large amount or blood cells, indicating damage to capillaries that is very
severe enough to allow the escape of RBCs from plasma
 This type of exudate is frequently seen in open wounds.
 Nurses often need to distinguish whether the exudate is dark or bright. Bright indicate
fresh blood, whereas dark exudate denotes older bleeding.
CARING FOR WOUNDS
Cleansing wounds: an area where ritualistic practice predominates
Key questions:
1. Does the wound really need cleaning?
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2. What is the safest method that causes no ill effects and maintains the wound temperature?
3. What is acceptable to the patient?
Wounds that are clean and healthy do not require cleaning and should be left alone
 Cleansing wounds: Main reasons
 Excess exudate and signs of infection
 Foreign body contamination ( e.g. grit in a graze)
 Presence of devitalised tissue ( slough or necrotic tissue)
 To assess the wound
 psychological reasons
 Cleansing wounds: Main reasons
 Excess exudate and signs of infection
 Foreign body contamination ( eg. grit in a graze)
 Presence of devitalised tissue ( slough or necrotic tissue)
 To assess the wound
 psychological reasons
Types of Cleansing Fluids
 Antiseptics: generally discouraged now- can be toxic to tissue healing
 Saline solutions: normal saline sachets commonly used
 Tap water: Why not!!
tip: cleansing fluids should be at body temperature
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Methods of Cleansing
 Swabbing: not particularly effective, mainly redistributes organisms
 Bathing: useful for chronic wounds such as leg ulcers. Take care with equipment to
avoid cross contamination
 Irrigation: shower head, water-jug, syringes – do not be overzealous
Choice of Dressing
The concept of moist wound healing
Modern dressing technology is based on the principle that the wound/dressing interface should
be moist rather than dry.
Common characteristics of wound dressings
 Capable of maintaining high humidity at wound site
 free of particles and contaminants
 non toxic/non allergenic
 capable of protecting the wound from further trauma
 Impermeable to bacteria
 thermally insulating
 capable of allowing gaseous exchange]
 able to withstand infrequent changes
 cost effective
 long lasting
Patient Factors influencing the choice of dressing:
 Age
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 Lifestyle
 Medical History
 Care environment
 Ability to maintain /change own dressing
 Competence and willingness of potential careers
Examples of Dressings
 Low adherent dressings-Tullegras,Tegapore
 Semi permeable films- Opsite, Tegaderm
 Hydrocolloids - Comfeel plus, Granuflex
 Hydrogels- Intrasite, Sterigel
 Alginates- Sorbisan, Kaltostat
 Foam dressings- Cavicare, Lyofoam extra
 Antimicrobial dressings- Actisorb plus, Inadine
TYPES OF DRESSINGS
Dry - to - dry:
Used primarily for wounds closing by primary intention.
Layer of wide mesh cotton gauze lies next to the wound surface, second layer of dry absorbent
cotton to protect the wound
Dressings for DRY wounds
 Transparent: gas exchanged between wound & environment but bacteria prevented
from entering. Creates moist healing environment Example: Tegaderm
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 Hydrogels: High water content enhances epithelialization and autolytic debridment.
Needs cover dressing and wound edge barrier
Example: Carrasyn
 Wet–to-Moist Gauze dressings: keeps wound bed moist. Minimizes trauma to

granulation tissues.
Wet – to
Moist
Gauze
TYPES OF DRESSINGS
Wet – to – dry:
These are particularly useful for untidy or infected wounds that must be debrided and closed by
secondary intention
Layer of wide mesh cotton gauze saturated with saline next to wound surface, second layer of
moist absorbent with same solution to debride the wound.
Wet –to – damp:
Variation of wet to dry dressing.
Wet – to wet:
Used in clean open wounds.
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Layer of wide mesh gauze saturated with antibacterial solution next to the wound surface, second
layer of absorbent material saturated with the same solution to dilutes viscous exudates.
 Dressings for MOIST wounds
 Hydrocolloid: hydrophilic particles mix with water to from a gel. wound stays moist.
DO NOT use in infected wounds.
Example: Duoderm
 Absorption Materials: beads, powders, rope or sheets that absorb large amount of
exudate
Example: Calcium Alginate
 Foam: Made of hydrophilic material. Highly absorbent.

Example: Allevyn
 Dry Gauze: Can absorb wound drainage. Can be impregnated with agents to promote
healing
 Dressings for MOIST wounds
Assessment
1- Patient allergies to wound cleaning agents.
2- The appearance and size of the wound.
3- The amount and character of exudates.
4- Patient complaints of discomfort.
5- The time of last pain medication.
6- Signs of systemic infection (e.g. elevated body temp, diaphoresis, malaise).
REQUIREMENTS
Top shelf
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3 gallipots for lotion for lotion, 2 pairs of dressing forceps, 2 pairs of dissecting forceps, sinus
forceps, probe, covered bowl for cotton wool and gauze swabs, covered receiver for dressing
towel, clip remover and stitch scissors or clip retractor (the above items can be in a dressing
pack)
Lower shelf
Bottle of lotion, adhesive plaster, scissors, bandage, covered receiver containing parazone 1:10
for soiled instruments, mackintosh with a cover, receptacle for soiled dressing, mask sterile and
disposable gloves.
Additional items:
-Moisture proof bag.
-Acetone solution to loosen adhesive.
-Sterile dressing set.
-Additional supplies (extra gauze dressing, and ointment if ordered.
-Tie tapes, tape or binder
PROCEDURE
1. Explain procedure to patient and ensure privacy. Provides information about the procedure
and promotes patient cooperation and also the privacy enhances the patient dignity.
2. Prepare and take trolley to the patient‘s besides.
3. Position patient comfortably and protect bed clothes. Ask patients whether they are
comfortable. Expose area of wound and remove plaster or bandage.
4. Wash and dry hands, assembly instruments and pour lotion into gallipots
Washing of hands reduces the transmission of microorganisms.
5. Remove soiled dressing with dissecting forceps or gloved hand and discard.
6. Wash and dry hands (remove old dressing towards the direction of hair growth) inspect
wound for colour, edema, drains, odour and size.
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7. Dab or clean wound with sterile forceps/gloves using prescribed lotion or gently irrigates
clean wound with syringe and saline from within outwards and clean the surrounding skin
(from the least infected area to the most infected area)
8. Clean or dab wound with series of swab until is clean (do not over clean to disturb the growth
of granulation tissue or to make the wound to bleed).
9. Apply sterile dressing using prescribed dressing lotion and secure into position with a plaster
(do not forget the rules of bandaging) or leave exposed where necessary.
10. Make patient comfortable in bed, explain the relevant findings to the patient (the appearance
of the wound, any indication of wound healing and what to eat or do to facilitate wound
healing) and thank him.
11. Discard trolley and decontaminate instruments and wash hands (this reduces the transmission
of microorganisms).
12. Remove gloves and screen, wash and dry hand
13. Document and report the state of the wound on the following; appearance of the wound,
colour, any discharges and its characteristics, the lotion used to clean and dressed the wound
and tolerance of patient to dressing.
Heat & Cold Therapy
 Heat- reduces pain & promotes healing through vasodilation
 Increases oxygen and nutrients to aid in inflammatory response
 Reduces edema by promoting removal of excessive interstitial fluid
 Promotes muscle relaxation
Heat & Cold Therapy
 Cold- decreases pain by vasoconstriction
 Decreased blood flow to the area decreases inflammation and edema
 Raises the threshold of pain receptors thereby decreasing pain
 Decreases muscle tension
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Safety Precautions
Heat & Cold Therapy
 Need physician’s order
 Very young and very old
 Peripheral vascular disease
 Decreased LOC (level of consciousness)
 Spinal cord injury
 Presence of edema and/or scar tissue
 NO LONGER than 20-30minutes at a time.

Rebound phenomena
No Cold to already edematous parts unless compartmentalized such as ankle or knee
Other Therapies
Electrical
Stimulation:
- electrical signals
direct cell migration
in wound healing
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Figure 1-12 Pictures of other therapies: Wound V. A. C (1st on the right up),
Hyperbaric Oxygen chamber (2nd from the right up), Hydrotherapy (1st on the right
bottom)
 Wound V.A.C. – negative pressure vacuum assisted closure system. Removes drainage
and helps wounds close.
 Hydrotherapy – Pulse lavage, Whirlpool Aids in debridement and cleansing, warm

water vasodilation.
 Hyperbaric Oxygen
 Electrical Stimulation
Minimising Cross Infection
 Dressing and cleansing wounds is at the very minimum a Clean Procedure and is often
an Aseptic Procedures
 Thorough hand-washing and use of gloves are the most effective methods of preventing
contamination of the wound
 If wounds are infected then care must be taken to prevent cross contamination
 Wound Evaluation
 Time of incident
 Size of wound
 Depth of wound
 Tendon / nerve involvement
 Bleeding at site
PATIENT INSTRUCTIONS AND FOLLOW UP CARE
Wound care
30
– After the first 24-48 hours, patients should gently wash the wound with soap and
water, dry it carefully, apply topical antibiotic ointment, and replace the
dressing/bandages.
– Facial wounds generally only need topical antibiotic ointment without bandaging.
– Eschar or scab formation should be avoided.
– Sunscreen spf 30 should be applied to the wound to prevent subsequent

hyperpigmentation.
REMOVAL OF STITCHES
Introduction
Sutures and staples are surgical means of closing wound by sewing, wiring or stapling the edges
of the wound together. Most wounds are sutured in layers to maintain alignment of the tissues
and reduce scarring. Sutures are generally removed 7-10 days after surgery depending on where
the wound is and how well it is healing. The removal is usually ordered by the surgeon. Timing
is relevant because sutures left in too long can increase the risk of wound infection and irritation.
Deep sutures in the tissue are usually absorbable materials. Surface sutures are made of wire,
nylon or cotton. Continuous sutures are made with one thread, tied at the beginning and the end
of the suture line. Interrupted sutures are tied individually. Staples are used for large incision
areas where dehiscence is greater such as in sterneotomies, in patients with increased adipose
tissue, abdominal areas and wounds that fail to heal or adhere. The methods of suturing are plain
continuous, plain intermittent, blanket continuous and blanket intermittent.
TYPES OF SUTURES
- Absorbable or non-absorbable (natural or synthetic)
- Monofilament or multifilament (braided)
- Dyed or un-dyed
Sizes 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed
by 0 indicate progressively smaller)
31
Figure 1-13 Diagram of the sizes of sutures
- New antibacterial sutures
Non-absorbable
These are not biodegradable and permanent. E.gs.
 Nylon (Ethilon)
 Prolene
 Stainless steel
 Silk (natural, can break down over years)
Absorbable
These are degraded via inflammatory response
Vicryl
Monocryl
PDS (Polydioxanone)
Chromic
Cat gut (natural)
Nylon (Ethilon®): of all the non-absorbable suture materials, monofilament nylon is the most
commonly used in surface closures.
Polypropylene (Prolene®): appears to be stronger then nylon and has better overall wound
security.
BRAIDED: includes cotton, silk, braided nylon and multifilament dacron. Before the advent of
synthetic fibers, silk was the mainstay of wound closure. It is the most workable and has
excellent knot security. Disadvantages: high reactivity and infection due to the absorption of
body fluids by the braided fibers.
SURGICAL INSTRUMENTS
32
Figure 1-14 Diagram of some surgical instruments Suture Removal Scissors, Dressing
Forceps, Tissue Forceps.
TYPES OF STITCHES
Simple Simple
interrupted continuous
suture suture
Figure 1-15 Diagram of simple interrupted and continuous sutures
Simple interrupted closure – most commonly used, good for shallow wounds without edge
tension
Continuous closure (running sutures) – good for hemostasis (scalp wounds) and long wounds
with minimal tension
33
INTERRUPTED HORIZONTAL MATTRESS SUTURE
Figure 1-16a Diagram of interrupted horizontal mattress suture
Figure 1-16b Diagram of vertical cross section interrupted horizontal mattress suture
Horizontal mattress – good for fragile skin and high tension wounds
VERTICAL MATTRESS SUTURE
34
1-17a Diagram of Vertical mattress
1-17 b Diagram of cross section of vertical mattress.

Vertical mattress – useful in maximizing wound eversion, reducing dead space, and minimizing
tension across the wound.
NEAR AND FAR SUTURE
35
1-18 Diagrams of near and far suture
SUB-CUTICULAR SUTURE
1-19 Diagrams of subcutaneous suture
Subcuticular – good for cosmetic results
36
CRUCIATE SUTURE
A
1-20a Diagrams of cruciate suture (A)
CONTINUOUS LOCK STITCH (FORD INTERLOCKING SUTURE)
37
1-20b Diagrams of different types of continuous lock suture (B)
Locking continuous - useful in wounds under moderate tension or in those requiring additional
hemostasis because of oozing from the skin edges.
REMOVAL OF SUTURE
1-21 Diagram of the removal of sutures

REQUIREMENT
Same as for dressing.
PROCEDURE
1. Explain procedure to the patient and ensure privacy. Provides information about the
procedure and promotes patient cooperation and also the privacy enhances the patient
dignity.
2. Wear mask, prepare and take trolley to bedside.
38
3. Put patient in a comfortable position, protect bed clothes to expose area to be dressed
only and pour out lotion into gallipots and remove plaster/bandage.
4. Wash and dry hands and put on gloves. Remove soiled dressing with dissecting forceps
and discard.
5. (Assess the wound for healing ridge and skin integrity of suture line for uniform closure
of wounds edges, normal colour and absence of drainage or inflammation.)
6. Clean wound with series of swabs soaked in antiseptic lotions,( from the least infected
area to the most infected are) placed sterile gauze near the Suture line.
7. Use the dissecting forceps and stitch removing scissors, grasp ends of the stitch with the
dissecting forceps and pull gently to expose an area between the knot and the skin.
8. Cut stitch between the knot and the skin; pull over suture gently and slowly.
9. Inspect carefully to make sure suture are removed and discarded on a piece of gauze note
the number of sutures removed. Make sure that the entire suture has been removed and
that no part of it has been retained in the patient’s wound and observe healing level.
10. Clean wound, apply dressing and secure into position
11. Thank and make patient comfortable in bed by asking whether he/she comfortable.
12. Discard trolley and decontaminate instruments.
13. Remove gloves wash and dry hands and remove screen.
14. Document and report state of wound on the following; appearance of the wound colour,
any discharges and its characteristic the location used to clean and dressed the wound and
the tolerance of patient to dressing. The time the sutures were removed, the number of
sutures removed, patient’s response to removal of the sutures and the level of healing of
the wound. Quickly notify the physician suture line separation, dehiscence, evisceration,
bleeding or purulent discharge.
REMOVAL OF CLIPS
Clips are stainless steel wires which are sometimes used instead of sutures but their uses are
restricted to some areas of the body, because there must be adequate distance between the skin
and the structures that lie below the skin including bone and vascular structures.
39
Clips are used at areas where cosmetic is not a priority, they provide ample strength and
abdomen, thigh and for patient with a repeat abdominal surgeries for greater strength to promote
wound closure.
1. Explain procedure to the patient, reassure and ensure privacy.

2. Ware mask, prepare dressing trolley and take to bedside.
3. Put patient in a desired position adjusts bed clothes to expose area to be dressed and
protect bed linen, pour out lotion into gallipots, remove plaster/bandage.
4. Wash and dry hands and put on gloves.
5. Remove soiled dressing with dissecting forceps and discard.
6. Swab wound with antiseptic lotion using another sterile forceps.
7. Place sterile piece of gauze near the wound and note the number of clips removed. Make
sure that the entire clips have been removed and that no part of it has been retained in the
patient’s wound and observe healing level.
8. Take clip removing forceps and dissecting forceps, steady the clip with the dissecting
forceps and inserts one black of the clip remover on top of it.
9. Press the blades together and then free the clip from the skin and either side place it on
the swab, note number of clips removed, inspect the wound for any abnormalities Clean
wound, apply dressing and secures into position.
10. Thank and make patient comfortable in bed.
11. Discard trolley and decontaminates instruments.
12. Remove gloves wash and dry hands.
13. Document procedure and report findings on the following; appearance of the wound,
colour, and discharge and its characteristics the lotion used to clean and dressed the
wound and the tolerance of patient to dressing. The time the clips were removed, the
number of clips removed, patient’s response to removal of the clips and the level heading
of the wound .Quickly notify the Physician of clips line separation, dehiscence,
evisceration, bleeding or purulent discharge.
CARE, SHORTENING AND REMOVAL OF DRAINAGE TUBE
If drainage accumulates in the wound bed, wound healing is delayed. Removal of every small
amount of drainage is accomplished by either a closed or opened drain system. The drain may be
40
inserted directly through the suture line or through a small stab wound near the suture line into
the wound.
An open drain system (a penrose drain) removes drainage from the wound and deposit onto the
skin surface. A sterile safety is inserted through this drain; outside the skin prevent the tubing
from moving into the wound. To remove the penrose drain the physician advances the tubing in
stage as the wound heals from bottom up.
A close drain system is sometimes connected to a vacuum or a suction device and drainage
collects into a drainage bag which is subsequently emptied. The closed system ensures dry skin
but operates only if the tubing is patent.
Dressing of the drainage tube must be done after cleaning of the incision site prevent infection of
the incision wound.
REQUIREMENTS
 Same as requirement for dressing of wound.

 Add sterile sharp pair of scissors
 Sterile safety pins
PROCEDURE
1. Explain procedure to the patient, reassure and ensure privacy

2. Wake mask, prepare dressing trolley and take to bedside
3. Put patient in a desired position, adjusts bed clothes to expose area to be dressed and
protect bed linen, pour out lotions into gallipots, remove plaster/bandage.
4. Wash and dry hands and put on gloves
5. remove soiled dressing with dissecting forceps and discard
6. swab wound with antiseptic lotion using another sterile forceps
7. Open the safety pins with a sterile forceps or a gloved hand
8. Grasp the protruding end of the drainage tube with an artery forceps and clip in position
9. Gently turn the drain within the wound to loosen it
41
10. Using the forceps, gently pull the drain out of the wound for a distance. At this stage
remove the drain if it is ordered that it should be removed. But if it should be shortened
then proceed to the next step.
11. Pass the safety pin through the tube out on the other side as near the skin surface as
possible and close it.
12. Cut the excess tubing off with a sterile pair of scissors.
13. Swab with cleaning lotion and apply drain-split gauze and secure with strips of plaster.
14. Make patient comfortable in bed, explain the relevant findings to patient (the appearance
of the wound, an indication of wound healing and what to eat or do to facilitate wound
healing) and thank him.
15. Discard trolley and decontaminate instruments and wash hand (reduces the transmission
of microorganism)
16. Remove gloves and screen, wash and dry hand.
CHANGING OF COLOSTOMY BAG AND CARE OF STOMA
Certain disease conditions require surgical interventions to create and opening into the
abdominal wall for feacal or urinary elimination e. g. colon cancer or trauma. Colostomy is a
surgical procedure performed to create an opening into the colon through the abdominal wall for
faecal matter elimination. The piece of intestine that is brought out onto the patient’s abdominal
wall is stoma.
REQUIREMENTS
Basin with warm or tap water, skin barrier, ostomy deodorant, mild detergent, pouch closer
device i.e. a clamp or artery forceps and a stethoscope as well as ostomy belt. Two pairs of
gloves disposable and sterile, mackintosh and dressing towel, large receiver, measuring jug, new
stoma bag, gallipot with sterile gauze and stoma adhesive.
PROCEDURE
1. Explain procedure to the patient and ensure privacy
2. Prepare and send trolley to bedside.
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3. Turn down top sheet to expose stoma.
4. Protect site with mackintosh and dressing towel
5. Put on disposable gloves and remove soiled bag gently and place in large receiver observe
stoma for colour, swelling trauma, peristomal skin and healing .stoma should be moist and
reddish pain, noting scars, folds, skin break down, observe effluent from stoma and record on the
intake and output chart. Remove disposable gloves wash and dry hands.
6. Put on sterile gloves, gently clean the peristomal skin with soap/mild detergent and warm tap
water by using sterile gauze.
7. Dry area gently with sterile cotton wool balls and apply barrier cream/zinc Oxide powderor
Vaseline
8. Estimate stoma or measure with measuring tape or guide and fit correct size of stoma bag.
9. Remove gloves, wash and day hands
10. Make patient comfortable and thank him (ask the patient whether he/she is comfortable)
11. Decontaminate and discards soiled articles.
12. Documents procedure and report any abnormalities, record the amount and appearance of
stool drainage bag size of stoma, colour and texture of stool, condition peristomal skin, sutures
and the skin barrier applied. Record patient’s level of participation and the need for teaching.
WOUND SWABBING
When caring for a patient with a wound the nurse assesses the wound condition and observes for
the development of infection. Localized inflammation, tenderness, purulent discharges and
warmth at the wound site usually signify wound infections. Infection cannot be confirmed or
treated or treated accurately unless the causative organism is identified. A specimen of wound
drainage is analyzed to determine the type and umber of pathogenic microorganisms.
43
REQUIREMENT; in addition to the items for dressing swab stick in a container, the lab
request form completed specimen identification label
PROCEDURE
1. Explain procedures to patient and ensure privacy
2. Put on mask and prepare trolley and take it to beside
3. Instruct assistant to
a. Put patient in a comfortable position and protect bed linen
b. Pour out lotions into gallipots
c. Expose wound area
d. Remove plastic/bandage
5. Remove soiled dressing with dissecting forceps and discards
6. Remove swab sticks gently from sterile container and insert the swab deeply into the wound,
from the most discharging part to the list discharging part by rotation it 360 degrees.
7. Replace the stick into the container and cork it to avoid contamination
8. Clean wound, apply dressing and secure into position.
9. Thank and make patient comfortable in bed
10. Discards trolley and decontaminate instrument
11. Remove gloves, wash and dry hands
12. Remove screen and label specimen
13. Ensure that the specimen is sent to laboratory with request form immediately.
44
14. Document procedure and reports on state of wound; Describe the appearance of the wound,
the characteristic of the drainage, the type of the specimen obtained, the patient’s tolerance of the
procedure and any evidence of infection and the time and date sent to the lab.
NOTES:
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CHAPTER TWO
INFUSION
It is the administration of fluid into the tissues or cavities of the body slowly a long period of
time.
Types of infusions
46
 The venous system
 Stomach or intragastric
 Rectal infusion
 Bladder irrigation (washout)
 Peritoneum (peritoneal dialysis )
 Extradura/Epidural analgesia
 Subcutaneous infusion
INTRAVENOUS THERAPY (infusion)
It is the prolong administration of drug, fluids and nutrients directly into a vein i.e. a needle is
passed through the skin and subcutaneous tissues into a vein.
Reasons for intravenous therapy
 It supplies the body with fluids and electrolytes especially in severe vomiting and
diarrhea
 It is given for rapid delivery of certain drugs when oral, subcutaneous or intramuscular
route are unsuitable or inadequate.
 It supplies the body with nutritious substances when the patients cannot absorb nutrients
through the G. I. T. (Total parenteral Nutrition)
 It supplies the body with one or more components of blood e.g whole blood, plasma and
packet cells.
Indications of intravenous therapy
 Any unconscious patient for more than 24hrs

 Severe diarrhea and vomiting.
 Sickle cell crisis
 Severe dehydration
 Severe bleeding
 Severe anaemia
 Severe burns/scalds/trauma
 Before and after operation (nil per os)
47
 Peritonitis and intestinal obstruction
 Septicaemia and toxaemia
Sites of I. V. therapy
 Cephalic vein
 Baslic vein
 Median vein
 Great saphenous vein
 Dorsal plexus
 Metacarpal plexus
 Scalp vein
 Umbilical vein in the new born babies
REQUIREMENTS
Wash and dry hands, and set trolley with the following items:
Top shelf
A galipot with sterile swabs, galipot for cleansing agent
Bottom shelf
-Infusion bottle/bag-Giving set – Sterile syringe and needles – infusion stand- Scalp vein
needle/right size of canula, - Strapping and scissors – Sterile glove pack- Vital signs tray.
- Cleansing agent e.g. methylates spirit or providine
- Protective mackintosh and a dressing towel
-Tourniquet/ sphygmomanometer 2 Receivers (one for sharpners and the other for used swabs).
-Bottles holder (where necessary)
- Intake and output chart.
PROCEDURE
48
Mounting the infusion:
1. Explain the procedure to patient, its purpose and what is expected of the patient as
well as the sensation patient is to expect and reassure him. The congnittive and
sensory information reduces the patient’s anxiety and promote cooperation.
2. Check the physician’s order for the type of solution and check the 8 right of drug
administration (right to information i.e. desire and side effects, the right to refuse the
drug the right documentation).
3. Ensure quality of the infusion (check for the colour, clarity, cloudiness, sediments,
other particles and expiry date as well as any leakage of the bag).
4. Send prepared trolley to the patient’s bedside.
5. Encourage patient to use bedpan and check vital signs.
6. Select and inspect sites and shave if necessary. Choose a site that will not interfere
with patient’s activities of daily living. Select a well dilated, easily palpable,
resilient, and soft and bouncy vein avoid sites that are distal to the previous
punctured site, hardened or bruised area.
7. Place infusion stands at the side of the bed and prepare plaster strips/tape.
8. Hang the bottle/bag on the drip stand. Compress drip chamber and release allowing
it to be 1/3 to1/2 full, be certain that giving set is clear of air bubbles.
9. Removes the cap from the other end of giving set and attach needle to it.
10. Protect the bed with dressing mackintosh and dressing towel
11. Expels air from the giving set.
Setting the infusion line
12. Wash hands, dry and wear sterile gloves and clean the site with antimicrobial
solution (methylated spirit) with cotton swab in a circular motion from middle to
outward. Stroke from proximal to distal, tap or ask the patient to open and close the
first to promote venous filling and venous dilatation.
13. Ask assistant to apply tourniquets to locate the vein. 10 to 12cm above anticipated
insertion site.
14. Introduce the needle into the vein and release the tourniquet. 10 to 30 degrees angle
15. Regulate the flow rate as ordered. Calculate the flow rate.
49
16. Secure canula into position and check for infiltration or haematoma.
17. Make patient comfortable in bed and instruct him to notify nurse when there is a
problem.
18. Check infusion rate accurately after 5 minutes and continue to observe the site of
insertion for swelling.
19. Thank patient, discard tray, wash and day hands.
20. Record time of setting up, and amount of fluid on the intake and output chart.
21. Document the following into nurse’s note; number of attempt at insertion, type of
infusion, flow rate size and type of cannula, time of infusion, patient’s response to
the i.v infusion, any side effect and adverse reaction such as pulmonary congestion,
shock and thrombophlebitis.
Points to remember in IV infusion
 Maintain sterile techniques throughout the procedure

 Regulate the flow rate as ordered land maintain steady rate of flow of the fluid. The
thicker the fluid the lesser the rate
 Instruction from the doctor should be obtained regarding increasing or decreasing of the
flow rate.
 Advise the patient or attendant to keep the hand in proper position and to watch for any
signs of swelling at the site of the needle.
 Observe the bottle frequently especially when the fluid is almost at the neck of the
infusion bag.
 Record the infusion on the intake and output chart.
 Clamp the fluid while changing for a second bottle.
Remedies for stoppage of flow
 Open the clamp or further loosen it.

 Turn the rubber air vent around.
 Observes if the rubber tube is kinked or twisted.
50
 Elevate the limb or change the position of the needle by placing a cotton swab under it.
 Message along the site of the needle.
 Observe is the patient has change position of the hand by bending putting pressure of
head over hand.
 Raise the height of the bottle on the fusion stand
 To release blockage of needle, fill a syringe with a little solution from the infusion and
with draw from the IV needles.
BLOOD TRANSFUSION
Blood transfusion is the introduction of whole blood or its components directly into circulation
through a vein.
TYPES OF BLOOD
Whole blood, packed cells, platelets, plasma,
Purpose for blood transfusion
 To increase blood volume

 To correct anaemia
 To replace blood product
 To increase the oxygen carrying capacity of the blood
Indications for blood transfusion
 Before and after major operations, e.g. cs, prostatectomy and hysterectomy
 Anaemia
 Severe haemorrhage, e.g. pph, aph
 Severe burns
 Haemophilia
 Severely debilitated persons
 Trauma
REQUIREMENTS
51
Set trolley with the following
Top shelf
A gallipot with sterile swabs
A gallipot with cleasing lotion
Bottom shelf
Infusion bottle with bottle holder infusion bag
Blood giving set, injection tray if pre-medication is prescribed
Sterile syringes and needle and the right size of canular
Plaster, splint, bandage and menthylated spirit
Tourniquet and infusion stand,
Vital signs tray
Mackintosh and dressing towel
2 receivers, one for used swabs and the other for used needles
A unit of blood, the prescribed premedication as ordered and
Tray for shaving including razor for shaving and scissors etc
Before transfusion
1. Inform and explain transfusion procedure and its importance to patients

2. Ensure that patient signs a consent form
3. Ensure that blood sample is taken and sent to the lab for grouping and cross matching.
4. Obtain baseline vital sign
5. Obtain the blood from the blood bank 30mins earlier before transfusion.
52
6. Double check the following information with a professional nurses or a doctor; patient’s
name, batch number, blood group and RH factor, expiry date, and compare with the
request form from the blood bank.
7. Be sure that the blood is not discolored, clotted or leaking and does not have bubbles.
8. Have patient void or empty urine bag.
During transfusion
1. Assembly transfusion items for the procedure.

2. Wash your hands and were gloves.
3. Invert the blood bag several times to mix blood with plasma.
4. Insert the giving set into the pact and expelled air.
5. Tighten the clip on the giving set.
6. Remove the sheath from the piercing needle and introduce needle into the appropriate
vein and apply strappings firmly in position.
7. Maintain asepsis throughout the procedure.
8. Regulate number of drops per minutes accordingly.
9. Record the amount of blood set up and the batch number on the fluid balance throughout
the procedure.
10. Monitor patient’s vital signs 5mins after transfusion and every 15 to 30mins throughout
the procedure.
11. Observe patient for the following transfusion reaction.
12. Chills, fever, headache, low back pains, chest pains, dyspnoea, hypotension, nausea,
flushes, itching, rashes and aggression and cough.
13. In case of reaction, stop blood and administer normal saline and send the blood back to
the lab.
After transfusion
1. Note the time and record.

2. Check vital signs at least 30 mins for one hour after the procedure.
3. Remove the cannula and apply firm dressing over the site.
4. Do not discard blood unit bag until 6-8 hrs.
53
5. Maintain strict input and output chart.
6. Inform patient to report any unusual symptoms immediately.
7. Observe for transfusion reaction mentioned.
8. document the blood group, Rhesus factor, batch number, names of those verifying, the
blood component, volume transfused. If there were any reaction and the interventions and
its effects, any premedication and dosage, ranges of vital signs.
Complications: haematoma formation, phlebitis, circulatory overload, sepsis, incompatibility

reaction, air embolism. Febrile reaction and allergic reaction.
PARENTERAL NUTRITION
Is a form of a specialized nutrition support in which nutrients including amino acids, glucose,
fatty acids vitamins, electrolytes, minerals and trace elements are given intravenously.
Indications: progressive weight loss, restricted fluid intake, intolerance to enteral feeding,
increased energy need (burns, sepsis, and trauma), NPO for more than 3 days, patients who are
unable to absorb or digest enteral nutrition and patient with short term nutritional needs (severely
malnourished patient)
A parenteral nutrition with greater than 10% requires a central venous catheter (CVC) that is
inserted into a high-flow central vein such as the superior vena cava. While a parenteral nutrition
less than 10% is given through a peripheral inserted central catheter (PICC) the catheter is
inserted through the forearm and threaded into the subclavian vein or the superior vena vein. (A
combination of amino acids and lipids) The parenteral nutrition solutions are usually
hyperosmolar and must be administered through a large diameter vein to prevent sclerosis of
vein.
The role of the nurse
1. Parental nutrition has significant physiological and psychological implications.

2. The nurse’s assessment provides information for the initiation of the appropriate
parenteral nutrition by consulting with the physician and the dietician
3. The nurse plays a role in the selection of an ideal vascular access for the procedure by
considering several factors e.g. duration or the therapy and the condition of the patient.
54
4. Patient who are unable to eat may become socially isolated and crave for food or even
hallucinate about food (majority of social events focus around food therefore excluding
the patient complete participation social events is the best)
5. The nurse promotes the patient’s psychological well-being by discussing possible
feelings and sensations; describing possible alternative to satisfy oral cravings such as
chewing gum, stick or sucking on hard candies (if allowed).
6. Provide activities that can help distract the patient from hunger, craving and promote
patient participation in social interactions and allowing visitors to come and visit patient.
7. Many patients who receive parenteral nutrition are capable of some oral concerns.
8. Patient and family education helps to alleviate are capable of some intake
9. The use of aseptic techniques before, during and after the fears and concerns.
1. 10 the solution should not be too cold or warm and should not be hanged for more than
12 hours.
10. Precaution should be taken to prevent air embolism and changing of the giving set should
be done quickly.
11. Maintenance of fluid and electrolyte balance is achieved by; maintaining adequate intake
and output chart, meticulous of the flow rate, daily weighing of the patient, blood for
electrolyte is checked daily as well as urinalysis for the presence of sugar and finally
signs symptoms of circulatory over load such as chest pains and difficulty in breathing.
12. Promotion of health is achieved by observing personal hygiene and mouth toileting,
treatment of pressure and serving of bed pans. Encourage the patient to maintain proper
elimination habit and support him or her in the performance of activities of daily living.
RECORDING INTAKE AND OUTPUT
It is the recording of the amount and the type of all fluids into the body and excreted from the
body over 24hrs period. By monitoring the amount of fluids a patient takes in and comparing this
with the amount of fluid the patient puts out, the health care team can gain valuable insights into
the patient’s general health as well as monitor specific disease conditions. To maintain good
health, fluid intake should approximately be equal to fluid output. Intake that exceeds output can
indicate medical conditions ranging from renal failure to congestive cardiac failure. Output that
exceeds intake can be caused by severe diarrhea or diuretic therapy. The nurse is responsible for
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recording all intakes such as oral fluids and by feeding tube, intravenous fluids, subcutaneous
fluids, rectal fluids and all ouptpu (urine, watery stool, vomits, gastric suction and drainage from
surgical tubes). Normally intake should be equal to output; if there should be a difference at all it
should not be so much. An output of less of less than 400 per 24hours is very serious.
Indications:
Patients with the following conditions, prolong fever, Oedema, patients on IV therapy, patients
receiving diuretics and steroids therapy, those on restricted fluids, severe vomiting and diarrhea,
severe burns and trauma, surgical wound drainage, those with impaired swallowing and
unconsciousness and patients with endocrine imbalance such as Cushing’s diseases and
Addison’s diseases.
REQUIREMENTS
Measuring container for inputs, measuring jug for outputs, fluids chart, pen and disposable
gloves
PROCEDURE
1. Explain to patients and family the reason for the fluid balance chart to gain the
cooperation. Explain to patient what constitute intake and output.
2. Explain the role patient has to play him (the role of the patient is vital since he would
provide information about accurate fluid intake and output, this will enable the doctor to
increase or decrease the dosage of the diuretic or for the doctor to know whether the
patient is responding to treatment or not.
3. Get requirement e.g. measuring jugs for intake and output, fluid charts and pen.
4. Record all measurement in millimeters
5. Write all entries clearly
6. Observe the amount of fluids given to patient (tea, water, soup, infusion) check and
records the amount taken in the intake column.
7. Record amount of infusion /transfusion and other fluid intake at intake column.
8. Record any output such as urine, watery and other fluid intake at intake column.
9. Total intake and output for 24hours depending on hospital policy.
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10. Find fluid balance by subtracting output from intake
11. Inform the nurse in charge/doctor immediately if amount of output is greater than the
amount taken in or when there is abnormally low output.
12. Document the total amount of the intake and output, the characteristics of the fluids such
as colour, odour and consistency in the patient’s folder, note the sign of fluid volume in
excess and deficit.
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CHAPTER THREE
PREPARING PATIENT AND TROLLEY FOR CHEST ASPIRATION AND ASSISTING

WITH PROCEDURE.
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It is an invasive procedure performed where a large-bore needle is inserted through the chest
wall into the pleural cavity for the purpose of removing fluid or administering medication
intrapleurally. The fluid removed is sent to the laboratory for analysis.
INDICATIONS
 Pneumothorax
o in any ventilated patient
o tension pneumothorax after initial needle relief
o persistent or recurrent pneumothorax after simple aspiration
o large secondary spontaneous pneumothorax in patients over 50 years
 Malignant pleural effusion
 Empyema and complicated parapneumonic pleural effusion
 Traumatic haemopneumothorax
 Postoperative—for example, thoracotomy, oesophagectomy, cardiac surgery
Figure 3-1 Equipment required for insertion of chest drains
REQUIREMENTS
o Two plain dissecting forceps- One artery forceps
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o Sterile syringes (5mls) and needles
o 50mls syringe with aspiration needle size 16.18 and 20
o 2 or 3 way stop cork with extension tub
o sterile gloves and masks
o Sterile towels and dressing
o Dressing mackintosh
o Receptacles and specimens bottle
o Local anaesthetic agents
o TPR tray with blood pressure apparatus
o A pair of scissors
o 2 Receptacle for used instruments and swab
o Adhesive strapping.
PROCEDURE
1. Explain procedure and the rational to patient and ensure consent form is signed
2. Determine whether patient is allergic to the antiseptic or anesthetic solutions
3. Assess the patient’s ability to assume the required position for the procedure
4. Assess the patient’s respiratory functions, respiratory difficulty, type of cough and
sputum produced.
5. Ensure that patient’s voids just before procedure to promote comfort and prevent
interruption Wash hands and prepare the trolley with the needed requirements.
6. Send trolley to beside and provide privacy.
7. Ensure chest X-rays ready this done to ensure the presence of the fluid in the pleural
space. Check vital signs and record to serve as a baseline.
8. Seat patient on the edge of the bed with his legs supported and his head and folded arms
resting on the over table OR have embraced on a chair backward and rest his head and
folded arms on the back of the chair (straddle). OR if not able to sit, position patient by
turning him on the unaffected side with the arm of the affected side raised above his
head, elevates the head of the bed 30-45 degree.
ASSISTING WITH THE PROCEDURE
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9. Maintain patient position throughout procedure if possible hold patient’s shoulders
sides and provide reassurance.
10. Protect bed linen with mackintosh and sterile towel or paper
11. Remind patient not to cough, breathe deeply or move suddenly during the procedure
12. Expose the whole area and shave (when necessary), clean the area with antiseptic
solution and cover the area with dressing towel.
13. Wash hands and hold the anaesthetic and assist the doctor throughout procedure.
14. Check vital signs, general condition and level of pain throughout the procedure
15. Secure tube in position with a firm dressing and strapping.
16. Make patient comfortable and thank him (turn patient on the unaffected side for l hour to
prevent the leakage of the punctured site).
17. Discard trolley and decontaminate used instrument, wash and dry hands.
18. Label specimen and ensure specimen is taken to laboratory for any ordered test.
19. Monitor vital sign 15mins for one hour as the condition is stable check every 30mins for
hours.
20. Observe the patient for fainting, diaphoresis, rate and effort to breath as well as the colour
of mucous membrane and nail beds
21. Document procedure and the following finding in the nurse’s note; location of the
punctured site, amount and colour of the fluid drained, duration, tolerance, the type of test
ordered and the dressing over the puncture site. Observed for any complication, the
interventions and the effect.
BRONCHOSCOPE
Is the examination of the trachea- bronchia tree through a lighted tube containing mirror called
bronchoscope. The bronchoscope is a flexible fibre optic that allows both visualization and
simultaneous administration of oxygen.
Purpose
-For detection of lesion,

- Obtain of sputum
-Removal of foreign body and
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- Obtain biopsy specimen
- To identify some abnormalities of the respiratory mucosa e.g. abscesses, strictures and
tumours
INDICATIONS;
Abnormal chest x-ray showing; lesion, atelectsis

Haemoptsis, unexplained cough, localized wheeze or stridor.
CONTRAINDICATIONS;
Patients who cannot receive oxygen during the procedure

Lack of consent,
Myocardial infarction,
Unstable angina and hypoxemia.
Nursing Implication
 The procedure & purpose of procedure is thoroughly explained to the patient.

 A consent form is signed by patient.
 The patient is asked to remove artificial dentures, jewelry and clothing.
 A gown is given to the patient wear.
 The patient is kept for at least 6-12hours of fasting
 Assess respiratory status: type of cough, sputum produced, and lung sounds.
 Pre-medication like atropine is usually given 1 hour before investigation.
 Ensure the presence of a current chest X-ray is available
 Check vital signs and record.
 Patient is asked to empty bladder before procedure.
 Serve the prescribed sedative or atropine
 The patient’s throat is anaesthetized with local spray.
 In sitting or supine or side lying or semi-fowlers position the doctor introduces the
bronchoscope either by mouth or nose.
 The patient is told that the procedure may cause discomfort, blood stained sputum, irritating
cough.
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 Oral hygiene is maintained before & after procedure.
 He is asked to empty bladder before & after procedure
 After the procedure the patient gag reflex is checked before offering food or fluid. Gag reflex
returns 2-4 hours after the procedure. Use tongue depressor to test the pharynx
 Check vital signs frequently; 15 for an hour, 30mins for 24hours and hourly until the
condition is stable
 Label specimen and send to the laboratory immediately with the request form
 Observe for any complication mentioned below.
 If procedure is done under general anaesthsia, post anesthetic care should be given
 Provide emesis bow for expectoration of sputum.
 Document in nurse’s note the duration of the procedure, patient response of the procedure
and complications, the specimen obtained, any change in the vital signs and the level of
consciousness of the patient as well as the medications administered.
Complications: hypoxemia, hypotension, laryngoscospasm pneumothorax, haemoptysis.
BRONCHOGRAPHY
This is a special X-ray examination of the lungs. It involves an introduction of iodized oil which
is radio- opaque into the bronchi, so that X-ray films can be taken to outline each bronchial tree.
The procedure is done to reveal neoplasm of the lungs.
Pre- nursing intervention
1. Psychologically, inform and give simple explanation to the patient and answer any
concerns the patient might raise.
2. Ensure that a consent form is signed
3. Three days before the procedure the patient is given 600mg of potassium iodine 3 times
daily to increase expectoration. Thus accumulation of secretion in the bronchi is removed
by coughing so that when the contrast agent is introduced into the bronchial tree a better
filling is obtained. Is obtained. It also tests whether the patient is allergic to the iodine or
not.
4. Patient is taught to perform postural drainage exercise 3days before the procedure is
performed to reduce bronchial secretion.
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5. The patient is asked to omit breakfast
6. Injection Atropine is given subcutaneously injection 30mins before the procedure is
performed to reduce bronchia secretion
7. Ensure that he patient wears on open- backed gown.
8. Remove jewelry, glasses and dentures
9. The dye may be introduced per nasal catheter or via a catheter introduced percutaneously
through circothroid membrane.
Post- nursing intervention
1. The procedure can be performed either by local or general anaesthesia
2. Keep the patient in bed until he is fully conscious. Even if the examination is done under a
local anaesthesia let the patient remain in bed for a few hours as the procedure is very tiring and
can be quite distressful.
3. Nil per os for at least 3hours after the procedure until the trachea anaesthesia is worn off.
4. Monitor the patient vital signs half hourly for 2 hours to prevent any respiratory distress.
5. Give a month wash after the procedure.
6. Patient receives extensive physiotherapy to enable him expectorate any oil or secretion left in
the lungs.
X-RAY
X-rays are useful diagnostic and therapeutic investigation because of their ability to penetrate
deep into the anatomical structures of the body
Simple X-rays (plain X-rays in which no contrast media are used)
Purpose of straight X-ray is to
 To examine bong structure, tumour and fractures.

 Presence of gas
 For stones in gall-bladder or urinary passage.
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 For any calcified tissue
 Thoracic structure and organs
INDICATIONS: intestinal obstruction, fractures, foreign bodies in a cavity etc
Nursing preparation before x- ray
 Explain to the patient about the procedure and why it is required

 Reassure the patient
 Arrange a suitable time with the x-ray department
 Take along the previous x-ray film
 To avoid feeling bored waiting for X-ray in waiting room, the nurse should provide book or
magazine to read for literate and conscious patient.
 It is better to wear a plain cotton clothing while going for X-ray
 The nurse should ensure that metallic object in area of X-ray exposure should be removed
like button, brassier fastenings, and hair, and clips, zips ornaments and be kept in safe
custody.
 Elastoplasts, Kaolin and plaster of Paris are shown up in X-ray
 For unconscious and very nervous patient the nurse should accompany the patient & for child
the mother.
ARTERIOGRAPHY (ANGIOGRAPHY) CARDIAC CATHETERIZATION
ARTERIOGRAPHY: It means examination of arteries or vessels. The procedure consists of

inserting a catheter into femoral, carotid or brachia artery and an opaque dye is injected through
the catheter and observed by fluoroscopy. The dye may be directly injected into vessels. The
procedure takes about 1-2 hours.-
Indication: occlusion, stenosis, emboli and thromboses of the arteries, aneurysms, tumuors,
congenital malformation of the arteries and trauma of the arteries of the major organ of the body.
CARDIAC CATHETERIZATION: is an invasive procedure where a catheter is inserted into

either the right or the left side of the heart to study the structures and the functions of the heart
after a contrast medium is injected intravenously. It is sometimes done to measure the pressures
within the heart.
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In right- sided or pulmonary cardiac catheterization, this investigation gives information
about the right side of the heart and pulmonary circulation. Usually the Sub-clavian vein and the
femoral veins are used for the vascular access. This vein is punctured with a stilted needle. The
stiletto is then removed and a guide wire is threaded through the needle into the vein as far back
as the inferior vena cava. The needle is removed and the appropriate catheter is passed over the
wire until it is in a satisfactory position. Fluoroscopy is done to judge the position of the catheter
and small injection of contrast medium is given to confirm position.
The left sided or coronary cardiac catheterization, the femoral, brachia and carotid arteries
are used to thread the catheter into the left heart and the coronary arteties.
INDICATION: Hole – in –heart, valvular malfunction, and coronary occlusion.
 Explain the purpose of the procedure to patient. Allow him to ask questions and answer them
in simple clear terms and also reassure him.
 Inform the patient about the sensations he may feel when the catheter and the contrast
medium are introduce such as feeling of pressure or warm flush.
 Ensure a consent form is signed by patient
 The area of insertion is shaved, cleaned with antiseptic lotion and covered with dressing
towel.
 Keep the patients fasting for 6-8 hours before the actual procedure
 Pre- medication or sedatives may be given if advised.
 The patient is asked to remove any dentures, jewellery or clothing which may interfere
during procedure.
 Give gown to patient to wear.
 Check and record vital signs and weight
 Ensure that baseline renal function test is performed.
 Determine if patient is taking anticoagulant which will predispose him or her to severe
bleeding.
 Assist the physician throughout the procedure
 The catheter insertion site is aseptically prepared and a local anesthesia may be given.
 Explain the sensation the patient will fell during the procedure and inform him that there will
not be much pain.
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 After the procedure, pressure dressing is applied for 15-20 minutes at insertion site.
 The site is observed for hematoma and swelling if it occurs, cold compress is applied to the
site.
 BP and pulse is taken at 15 minutes interval.
 Attention should be paid to any numbness or tingling or pain
 Check for down steam pulse to ensure adequate circulation beyond the insertion point.
 Encourage the patient to lay flat for 6 to 12 hours to promote natural healing of the site
 Encourage patient to drink 1 to 2 litres of fluid after procedure
 Documentation: patient’s status after the procedure, changes in vital signs, the condition of
the i.v. site e.g. haematoma and the level of patient’s responsiveness, any reaction to the
contrast medium and patient’s tolerance level of the procedure.
Complications: haemorrhage and haematoma at the insert site, reaction of the dye, sepsis, renal
failure, stroke, myocardial infarction and pulmonary emboli.
ELECTROCARDIOGRAM (E. C. G)
This is a graphical recording of the electrical activity of the heart detected on the body by
electrodes and a galvanometer (E. C. G machine). The main purpose of the E. C. G is to diagnose
different heart disease such as cardiac rhythm disturbances and myocardial ischemia or
infarction. E. C. G may also reveal other cardiac structural or functional abnormalities such as
hypertrophy and valvular problem. The 12-lead E. C. G provides information about cardiac
electrical activity from 12 vantage points on the body surface. It noninvasive and painless and
can be obtained within a few minutes.
BEFORE THE PROCEDURE
 Explain the procedure with the rationale and reassure the patient
 Ensure that a consent form is signed
 Check vital signs and record
 Obtain previous E. C. G tracing if any
 Encourage the patient to take a bath the morning of the procedure but should not apply any
cream or lotion or grease on the body
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 Inform the patient that it may be necessary to shave body hair at some sites where electrodes
are to do placed to provide good contact
 Ask patient to remove all metallic accessories e. g. rings, earrings,
 Inform the patient to breathe normally and refrain from talking throughout the procedure
 Remove patient clothing and replace with operating gown
 Send patient to the E. C. G unit at the appointed time
 Place patient in the required position (supine and instruct patient to lie still
 Reassure patient.
DURING THE PROCEDURE
 Wash and wipe hand and inform patient

 Apply electrode paste and attach electrodes to the chest.
 Provide privacy and prepare the site with methylated spirit.
 Apply electrodes paste and attach leads according to the instructions.
 Inform patient and turn on the machine
 VI-4TH intercostals space (ICS) at right sterna border. For females choose a site as close to
standard as possible.
 Vii-Midway between Vii and Viv
 Viv-5th ICS at midclavicular line
 Vv-Left anterior auxiliary line at level of Viv horizontally
 Vvi- Left mid-axillary line at level of Viv horizontally
 Extremities- one lead on each extremity: arms and legs
 Obtain tracing from the machine after the procedure
 Inspects tracing for adequate quality
 Remove leads and electrodes. Wipe excess paste from the chest and help the patient to dress
up
 Inform physician about abnormality or send E. C. G tracing to the appropriate unit
 Wash hands
 Check and record vital signs
 Return machine and replace supplies
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 Document the entire procedure.
ECHOCARDIOGRAPHY (ECHOCARDIO)
This is another mode if investigation to determine functioning of the heart. It consists of imaging
of the heart by the use of ultrasound beam to the tissues, the reflected sound waves or echoes
from the heart are converted to electrical impulses and recorded on a chart.
This procedure is useful in the detection of mitral stenosis, pericardial effusion, congenital heart
disease, valve conditions and left ventricular function. The procedure takes about 30 minutes
Nursing implications
 The procedure and the purpose is explained to the patients

 Reassure the patient
 Check and record patient’s vital signs
 Obtain the previous results if any
 The patient is undressed up to the waist line
 Gown the patient in cotton dress
 Send patient to the unit at the appointee time
 Ask patient to remove all metallic accessories e.g. rings, earrings and cell phones
 The operator applies a special lubricant to the skin surface at the site to be examined (chest
area)
 The transducer is moved by hand across the chest
 During the procedure the patient is asked to remain silent
 The patient is informed that the procedure is painless and does not produce any discomfort.
 Wipe the lubricant from the skin and make the patient comfortable.
 Documents your findings.
PRINCIPLES FOR INSERTING AND MANAGING CHEST DRAINS
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The insertion of a chest drain can be a frightening procedure for patients. The technique of
inserting a drain, the nurse’s responsibilities when managing these patients, and emphasises the
importance of explaining the process to them and their need for analgesia.
Chest drains are placed in the pleural or mediastinal space to evacuate an abnormal collection of
air, fluid, pus or solids that may have collected as a result of injury, disease or surgical
procedures (Munnell, 1997; Kirkwood, 2002) (Fig 1). Any abnormal collection of fluid or air in
the pleural space can compress the lung, causing it to collapse either partially or fully, which can
seriously compromise ventilation and the mechanics of breathing (Allibone, 2003). Insertion of a
chest drain will allow drainage of the pleural space and help to restore and maintain the negative
pressure between the visceral and parietal pleural membranes, allowing full expansion of the
lung (Hyde et al, 1997).
A chest drain is usually attached to an underwater seal drainage system, which acts as a one-way
valve allowing fluid and air to leave the pleural space during expiration and coughing but which
prevents it from being sucked back in during inspiration.
How are chest drains inserted?
A doctor inserts a chest drain under aseptic conditions. Patients are usually positioned on the bed
with their arm on the affected side placed behind their head to expose the axillary area.
Alternatively, they can lean over a table covered with pillows for support (Laws at al, 2003).
Insertion of a chest drain is reported to be a painful and frightening procedure, and patients must
be given an explanation of what is going to happen and an assurance that they will receive
analgesia before the procedure is carried out (Bourke, 2003; Luketich et al, 1998).
The skin where the drain is going to be inserted must be cleaned according to local policy,
following which a local anaesthetic is injected around the insertion site.
Once the local anaesthetic has taken effect, the area where the drain is going to be inserted is
covered in sterile drapes and an incision is made at the site. The most common position for chest
tube insertion is the mid-axillary line, through the position described as the ‘safe triangle’ (Fig
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2). This position minimises the risk of damage to structures such as the internal mammary artery
and avoids damage to muscle and breast tissue that can result in unsightly scarring (Laws et al,
2003).
Blunt dissection of the subcutaneous tissue and muscle around the pleural cavity is achieved
using forceps or the doctor’s finger. Using a trocar (a chest drain with a metal introducer)
increases the risk of damage to major organs (Laws et al, 2003; Henry et al, 2003; Hyde et al,
1997), however blunt dissection can be more time-consuming (Munnell, 1997).
Ideally, the position of the tube tip should be aimed towards the apex of the lung for a
pneumothorax (air in the pleural space) or towards the base of the lung to remove fluid, for
example, blood (haemothorax). However, it is suggested that any position can be effective at
draining air or fluid (Laws et al, 2003; Tang et al, 1999).
How is the chest drain secured?
Two sutures are inserted: one anchors the drain in place and the other assists with later closure of
the wound after removal of the drain. Laws et al (2003) suggest that a mattress-style suture
(across the incision) be used for wound closure rather than the traditional purse string suture,
which can cause puckering of the skin and unsightly scars.
Current recommendations on taping the connection between the chest and drainage tubes conflict
(Avery, 2000; Godden and Hiley, 1998); however, what is known is that without any additional
method of security, such as tape, there is a risk of their becoming disconnected. The potential
complications of chest drain insertion are summarised in Box 2.
NURSES’ RESPONSIBILITIES WHEN MANAGING A CHEST DRAIN
It is important that nurses receive appropriate training in the management of chest drains and
ensure that patients are cared for safely and competently (Laws et al, 2003)
Observation of the patient
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A chest X-ray must be performed after a chest drain has been inserted to verify its correct
placement, the degree of re-expansion of the lung and the residual pleural fluid and/or
pneumothorax.
The patient’s vital signs must be monitored closely, and respiratory function assessed for signs of
improvement or deterioration. Observations should include breath sounds and equality of chest
movements, respiration rate, pattern, depth and effort associated with breathing (Mallett and
Dougherty, 2000; McMahon-Parkes, 1997; O’Hanlon-Nichols, 1996). If any deterioration or
distress is detected, the medical team must be notified at once and another chest X-ray should be
ordered.
The patient and the chest drain site should be assessed at least daily for signs of systemic or local
infection.
Observations of the drainage system
The drainage bottle must be kept below chest level to prevent fluid re-entering the pleural space.
The activity of the chest drain, including fluctuation of the water level in the underwater seal
chamber (swinging) and the bubbling of air through the underwater seal, should be monitored.
The fluid level in the underwater seal drain should be checked regularly and the level of drainage
marked on the bottle each time, as therapeutic decisions are based on the quantity of drainage
(Light, 2001) and its colour and consistency. The frequency of recording will vary depending on
the condition of the patient and the amount of fluid expected to be lost (Avery, 2000; McMahon-
Parkes, 1997).
Immediately after chest surgery the extent of the drainage must be monitored every 30 minutes.
Following thoracic surgery, the patient may drain up to 100ml/h of blood and haemoserous fluid
for three to four hours. If drainage suddenly ceases, this may indicate that the drain is blocked. If
there is an increase in blood and haemoserous fluid this may be an indication of haemorrhage,
and the nurse should inform medical staff (Nelson and Tully, 1998).
72
It is recommended that a large pleural effusion be drained slowly to avoid the risk of re-
expansion pulmonary oedema. The reason for this being a risk is not clear, but it may be due to
an increased permeability of the pulmonary vasculature or because of the lung re-expanding too
quickly. Laws et al (2003) suggest that no more than 1,500ml should be drained at one time, and
that following drainage of this volume, subsequent drainage should be reduced to 500ml an hour.
However, there is no evidence for what the actual amounts that should be drained at one time
should be.
Pain management
Parkin (2002) suggests that there are no guidelines or protocols for the assessment and
management of pain associated with chest drains. However, chest drains can cause pain (Hilton,
2004; Gray, 2000), and inadequate analgesia may inhibit both movement and lung expansion
and, consequently, patient recovery (McMahon-Parkes, 1997). Current management regimes
include patient-controlled analgesia, paravertebral blocks, non-steroidal anti-inflammatory drugs
or transcutaneous electrical nerve stimulation.
Suction and chest drains
Suction may be attached to the underwater seal drain to manage a non-resolving pneumothorax
following thoracic surgery or to facilitate drainage of a pleural effusion. Ideally, a high volume
/low-pressure system should be used (Henry et al, 2003; Laws et al, 2003; Hyde et al, 1997).
There is currently no consensus on how much suction should be applied (Avery, 2000), but the
most commonly used pressure is 5 kilopascals (Avery, 2000).
Clamping drains
Clamping a chest drain tube can increase the risk of a tension pneumothorax. This occurs when
air from the alveoli enters, but cannot leave, the pleural space. The air can build up, causing a
mediastinal shift towards the unaffected lung, leading to compression of the vena cava, which is
associated with shock and collapse. The condition can be fatal. If bubbling is observed in the
underwater seal drain, the chest tube should never be clamped. A non-bubbling chest drain
should not usually be clamped except momentarily in the event of its being disconnected, if there
73
is damage to the drainage bottle, or to locate a leak in the drainage system (Henry et al, 2003;
Laws et al, 2003; Munnell, 1997; Avery, 2000).
If controlled drainage of a large pleural effusion is required, the drain may be clamped in the
initial stages to prevent the risk of re-expansion pulmonary oedema (Laws et al, 2003).
Milking and stripping drainage tubing
Studies have shown that routine milking or stripping of tubing to maintain the patency of the
drainage system should be avoided as this increases the negative pressure in the intrathoracic
cavity (Kirkwood, 2002). Avery (2000) suggests replacing the tubing if it becomes blocked.
Changing drainage bottles
If too much fluid collects in the drainage bottle, resistance to drainage increases (Munnell, 1997).
The force required to overcome the underwater seal increases in proportion to the height of the
water column (Compeau and Johnston, 1999). However, there is no consensus about how often
the bottles should be changed (Godden and Hiley, 1998). The manufacturer’s recommendations
and local policies will need to be consulted.
A one bottle/one chamber device is generally adequate to evacuate an uncomplicated

pneumothorax, haemothorax or pleural effusion). However, several drainage systems are
available, and some units incorporate two or more chambers in one bottle to separate the
drainage fluid from the water seal.
Drainage tubing
Ideally, the drainage tubing should be laid horizontally across the bed or chair before dropping it
vertically into the drainage bottle (Avery, 2000; Munnell, 1997; O’Hanlon Nichols, 1996). This
is because looped drainage tubing can impede drainage, so increasing pressure in the tubing,
which can lead to a tension pneumothorax or surgical emphysema (air in the subcutaneous
tissue) (Kirkwood, 2002; Avery, 2000). The patient can be encouraged to lift the tubing every 15
minutes to promote drainage (Schmeltz et al, 1999).
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Mobility with a chest drain
Patients should be encouraged to walk around the ward or exercise around the bed if their drain
is attached to wall suction. This facilitates drainage and prevents stiffness of the shoulder joints.
Deep breathing exercises and coughing should be encouraged so as to open the airways and
increase intrathoracic pressure and promote re-expansion of the lungs (McMahon-Parkes, 1997).
Removal of the chest drain
Chest drains are usually removed when the drainage is less than 100-150ml over 24 hours, breath
sounds have returned to normal, bubbling in the underwater seal drain has ceased and the chest
X-ray shows that the underlying problem has been resolved. Two nurses must perform the
procedure: one removes the drain, the other ties the suture to close the wound. If the patient has
had a pneumothorax, the chest drain should not be clamped when it is removed (Laws et al,
2003). Analgesia and a full explanation of the procedure must be given to patients.
Before any attempt is made to remove the drain, the position and viability of the suture used to
close the wound should be inspected to ensure that it will close the site. If in doubt, the medical
staff should be notified, as a further suture may be required before removing the drain (Allibone,
2003).
In order to reduce the complication of recurrent pneumothorax, Valsalva’s manoeuvre can be

used. This requires patients to hold their breath and to bear down or try to breathe out against a
closed glottis. This increases the intra-thoracic pressure, which reduces the possibility of air re-
entering the pleural space through the drain site. The drain can be removed while the patient is
holding his/her breath or on expiration (Tang et al, 1999; Miller and Sahn, 1987). However, there
is no consensus in the literature regarding the optimum breathing technique. As soon as one
nurse has briskly removed the drain, the other nurse immediately ties the suture in order to form
an airtight seal. The patient can then breathe normally. A chest X-ray should be performed to
check that a pneumothorax has not recurred, and both the patient and the drain site should be
monitored closely.
WATER-SEAL CHEST DRAINAGE OR UNDER SEAL WATER DRAINAGE
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a. General. Underwater-seal chest drainage is a closed (airtight) system for drainage of air and
fluid from the chest cavity.
(1) The underwater-seal system is established by connecting a catheter (chest tube) that has been
placed in the patient's pleural cavity to drainage tubing that leads to a sealed drainage bottle.
(2) Air and fluid drain into the bottle, but water acts as a seal to keep the air from being drawn
back into the pleural space.
(3) By keeping the drainage bottle at floor level, fluid will be prevented from being siphoned
back.
(4) As air and fluid are drained, pressure on the lungs is relieved and re-expansion of the lung is
facilitated.
b. Selection of the System. The physician will specify the drainage setup he prefers to use. It is a
nursing responsibility to be familiar with the various systems and their operation.
(1) When the physician specifies his preference, the nursing personnel will obtain, assemble, and
check the system, maintaining asepsis within the system.

(2) Chest drainage can be organized into three types of systems. Each can be used with or
without suction. Refer to Figure 3-1 and 2 as you read the descriptions that follow.
Figure 3-2 Water-seal drainage system
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Figure 3-3 Chest drainage systems. (A) Strategic placement of a chest catheter in the
pleural space. (B) Three types of mechanical drainage systems. A Pleur-vac operating
system: (1) the collection chamber, (2) the water-seal chamber, and (3) the suction control
chamber. The Pleurevac is a single unit with all three bottles identified as chambers
(Lippincot Manual of Nursing Procedures).
c. The Single-Bottle Water-Seal System.

(1) Connecting or drainage tubing joins the patient's chest tube with a drainage tube (glass rod)
that enters the drainage bottle.
(2) The end of the glass rod is submerged in water, extending about 2.5 cm (1 inch) below the
water level.
(3) The water seal permits drainage of air and fluid from the pleural space but does not allow air
to reenter the chest.
(4) Drainage depends upon gravity, the mechanics of respiration, and, if ordered, the addition of
controlled suction.
(5) The second tube in the drainage bottle is a vent for the escape of any air drained from the
lung. If suction is ordered, it is attached here.
(6) Bubbling at the end of the drainage tube may or may not be visible. Bubbling may mean
persistent air leaking from the lung or a leak in the system.
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(7) The water level in the bottle fluctuates as the patient breathes. It rises when the patient
inhales and lowers when the patient exhales.
(8) Since fluid drains into this bottle, be certain to mark the water level prior to opening the
system to the patient. This will allow correct measurement of patient drainage.
d. The Two-Bottle Water-Seal System.

(1) The two-bottle system consists of the same water-seal bottle plus a fluid collection bottle.
(2) Pleural fluid accumulates in the collection bottle, and not in the water-seal bottle (as in the
single-bottle system).
(3) Drainage depends upon gravity or the amount of suction added to the system.
(4) When suction is added, it is connected at the vent tube in the water-seal bottle.
e. The Three-Bottle Water-Seal System.

(1) This system consists of the water-seal bottle, the fluid collection bottle, and a third bottle
which controls the amount of suction applied.
(2) The third bottle, called the manometer bottle, has three tubes. One short tube above the water
level comes from the water-seal bottle. A second short tube leads to the suction. The third tube
extends below the water level and opens to the atmosphere outside the bottle. It is this tube that
regulates the suction, depending upon the depth the tube is submerged. It is normally submerged
20 cm (7.6 inches).
(3) The suction pressure causes outside air to be sucked into the system through the tube,
creating a constant pressure. Bubbling in the manometer bottle indicates the system is
functioning properly.
f. Commercial Systems.
There are several disposable commercial drainage systems available. They are plastic devices,
divided into chambers for fluid collection, water-seal, and suction control. Follow the
manufacturer's instructions for commercial drainage systems used at your facility.
CARING FOR THE PATIENT WITH WATER-SEAL CHEST DRAINAGE
a. When using suction with water-seal drainage, the system should be open to the
atmosphere when the suction is turned off for any reason. This will allow intrapleural air
to escape from the system. To do this, simply detach the tubing from the suction port to
create an air vent.
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b. Observe the water-seal chest drainage system for patency to ensure that it is functioning
properly.
(1) Fluid in glass rod (or water seal chamber of commercial devices) should rise and fall with
respirations.
(2) Fluctuation should continue until the lung has re-expanded.
c. Observe amount, color, and consistency of chest drainage at ordered time intervals and
record results in patient's clinical record.
(1) Notify charge nurse immediately if chest drainage exceeds 100 cc/hour.
(2) Notify charge nurse immediately if chest drainage color changes to indicate an active
bleeding problem.
(3) Mark the level of drainage on a piece of adhesive tape affixed to the drainage system every
shift, or as ordered; include date, time, and your initials.
(4) Do not empty the drainage system unless directed to do so by the physician.
d. Observe drainage tubing for any kinking.

(1) Do not allow drainage tubing to loop below drainage system entry level.
(2) Fasten the tubing to the draw sheet with rubber bands and safety pins so the flow by gravity
will occur.
e. Milk the chest tube, as ordered by the physician, in the direction of chest drainage to
promote chest tube patency.
(1) Lubricate the drainage tubing with lubricant (water-soluble) for approximately 12 inches.
(2) Pinch the tubing above the lubrication with one hand; with the other hand compress the
tubing, allowing the fingers to slide over the lubrication toward the drainage bottle and release
both hands.
f. Observe the patient carefully for any signs of respiratory difficulty, cyanosis, chest
pressure, crepitus, and/or hemorrhage.
(1) Monitor vital signs every 4 hours, or as ordered, and record.
(2) Auscultate patient's lung sounds every 4 hours and record findings.
g. Check to see that the drainage bottle is secured to the floor or is in a special holder.
(1) Prevent bottle from being kicked or tipped over.
(2) Caution visitors against handling equipment.
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h. Observe the dressing at the chest tube insertion site for air leakage or excessive drainage
and record findings.
(1) Dressing changes are performed only according to physician's orders.
(2) Observe skin condition during dressing changes and record.
i. Encourage the patient to cough and deep breath at least every 2 hours or as ordered.
(1) Patient should be assisted to a sitting position if possible to promote effective deep breathing
and coughing.
(2) A pillow or blanket should be used to splint the affected area.
j. Encourage the patient to change position every 2 hours to promote drainage and prevent
complications; make sure tubing remains free from kinks and is in proper position.
k. Encourage the patient to perform range of motion exercises for the affected upper
extremity to maintain joint mobility.
l. Transport or ambulate a patient with a chest tube carefully, keeping the water-seal unit
below chest level and upright at all times.
(1) Assist or instruct personnel from other departments in transporting or ambulating the patient.
(2) Nursing staff should accompany the patient.
(3) Disconnect the closed chest drainage system from suction for transportation or ambulation;
make sure air vent rod is open.
(4) Attach hemostats (Kelly Clamps) to the patient's hospital gown during transportation or
ambulation for emergency use.
m. As indicated, provide emergency care to the patient if the water- seal unit becomes
broken or emptied.
(1) Clamp the chest tube unless there has been a large air leak; chest tube with a large air leak
should be left open, since clamping may cause a rapid pneumothorax.
(2) Reestablish a closed drainage system.
(3) Remove clamps, if applied.
(4) Notify the professional nurse/physician, as indicated.
(5) Observe the patient for respiratory distress.
n. As indicated, provide emergency care to the patient if the chest tube becomes
disconnected from the drainage system.
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(1) Clamp the chest tube.
(2) Cleanse the end of the tubing with an antiseptic solution and reconnect or cut off the
contaminated tips of the chest tube and tubing and insert a sterile connecting piece.
(3) Securely tape the connection.
(4) Notify the professional nurse/physician, as indicated.
(5) Observe the patient for respiratory distress.
o. As indicated, provide emergency care to the patient if the water- seal unit is tipped over.
(1) Return unit to upright position.
(2) Instruct the patient to deep breathe and cough to force air out of the pleural space.
(3) Notify the professional nurse.
(4) Assess the patient for respiratory distress.
p. As indicated; provide emergency care to the patient whose chest tube has accidentally
been pulled out of the chest wall.
(1) Cover the site with sterile 4"x4" gauze sponges and tape occlusively.
(2) Notify the professional nurse/physician immediately.
(3) Monitor the patient for respiratory distress.
q. Record significant nursing observations in the patient's clinical record and report the
same to the professional nurse.
(1) Amount, color, and consistency of chest drainage.
(2) Presence or absence of air leaks or bubbling in the water-seal unit.
(3) Presence or absence of fluctuation in the glass rod of the water-seal unit.
(4) Time and results of chest tube milking. Specific observations about the patient, such as vital
signs, breathe sounds, and skin color.
(5) Results of deep breathing and coughing.
(6) Position changes or activity, including range of motion.
(7) Condition of chest tube insertion site and dressing.
TRACHEOSTOMY
a. A tracheotomy is the incision of the trachea through the skin and muscles of the neck. When
an indwelling tube is inserted into the surgically created opening in the trachea, the term
“tracheostomy” is used. A tracheostomy may be permanent or temporary. There are many
81
diseases and conditions that make a tracheostomy necessary. For example, a tracheostomy may
be done:
(1) To bypass an upper airway obstruction.
(2) To replace an endotracheal tube with a tracheostomy tube.
(3) To allow for extended mechanical ventilation.
(4) To facilitate removal of tracheobronchial secretions.
(5) To prevent aspiration in the comatose or paralyzed patient.
b. A tracheostomy tube (sometimes referred to as a tracheal cannula set) consists of three parts:
the outer cannula, the inner cannula, and the obturator. Refer to Figure -3.
Figure 3-3 Tracheostomy tube set

(1) The obturator is used by the surgeon as a guide when inserting the outer cannula into the
tracheal incision.
(2) After insertion of the outer cannula, the obturator is removed. The inner cannula is inserted
into the outer cannula and locked in place.
(3) Tracheostomy tubes may be metal or plastic. Plastic tubes that have an inflatable cuff
surrounding the outer cannula are the most commonly used. The cuff helps to hold the tube in
place, prevents aspiration of material into the lungs, and prevents leaking of air around the sides
of the tube.
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(4) The tracheostomy tube is kept in place by means of cotton twill tape inserted through the
slotted flanges of the outer cannula and tied around the patient's neck. A sterile dressing is placed
around the tube to protect the stoma.
TRACHEOSTOMY NURSING CARE
a. Preparatory Nursing Measures. In addition to routine preparation of the patient unit for
postoperative care, the following measures should be planned in advance.
(1) The patient will require constant attendance for at least the first 48 hours. The nursing
personnel must remember two important things: the patient's life depends upon a clear airway,
and the patient will have a temporary loss of voice. Therefore, the patient must be observed
closely for airway patency and immediate action taken when any adverse signs or symptoms are
present. The patient will feel anxious about his inability to communicate with his voice. Always
have the call bell available to the patient. Devise a temporary means of communication such as
writing notes or using flash cards so that the patient may communicate his needs to the nursing
personnel.
(2) For the first few days postoperatively, the patient should be kept in a room where the
temperature and humidity can be maintained at optimum levels. Increased temperature and
humidity will help to reduce the tracheal irritation that results when inspired air has bypassed the
natural warming and moisturizing of the nasopharyngeal airway.
(3) The patient's room should be supplied with a variety of equipment necessary to the care of
the patient. Such things include suction equipment, a spare tracheostomy tube set, and sterile
dressing material.
b. Postoperative Nursing Measures. In addition to routine postoperative nursing care, the
following nursing actions should be noted.
(1) Always apply basic principles of aseptic technique when caring for the incision and the
airway. When suctioning, use separate set-ups for pharyngeal and tracheostomy suctioning.
(2) Constantly observe the patient for signs of respiratory obstruction such as restlessness,
cyanosis, increased pulse, or gurgling noises during respiration.
(3) Watch closely for bleeding from the incision, and look for blood in the aspirated secretions
when suctioning.
(4) Be alert for choking or coughing when the patient swallows. This may indicate damage to
the esophagus with leakage of swallowed material into the trachea.
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PERFORMING TRACHEOSTOMY SUCTIONING
a. Assemble the necessary equipment.
(1) Portable continuous suction machine or in-wall suction.
(2) Sterile suction kit containing sterile suction catheters (14-18ºFr.), a sterile solution container,
and sterile gloves.
(3) Sterile saline in a pour bottle.
(4) Sterile gauze sponges.
(5) Sterile normal saline in 5cc packets for tracheal instillation, if ordered.
(6) Oxygen source with flow meter and a manual resuscitator (ambu bag).
(7) Waste receptacle.
b. Explain the suctioning procedure to the patient if he is conscious.

(1) Hyper oxygenation will be performed. An ambu bag with 100 percent oxygen will be
connected to the tracheostomy tube and the patient will be given several breaths prior to
suctioning. This is done to prevent shortness of breath or hypoxia.
(2) Approximately 5cc of normal saline will be instilled into the tracheostomy tube to help
liquify secretions. Inform the patient that this may stimulate a cough reflex.
c. Place the patient in semi-Fowler's position if permitted.

d. Wash your hands and set up the sterile suction kit.
(1) Open the suction kit, using the wrapper to create a sterile field. Place the sterile sponges on
the field.
(2) Pour 50-100cc of sterile saline into the solution container, using a septic technique.
e. Turn on the suction unit and set to low pressure to avoid trauma to the patient.
f. Using aseptic technique, don the sterile gloves.
g. Attach the sterile suction catheter to the connecting tubing by holding the catheter in your
dominant hand (sterile hand) and the connecting tube in your non-dominant hand (non-sterile
hand). Refer to Figure 3-4.
h. Moisten the catheter tip in the sterile saline.
i. Instruct your assistant to hyper oxygenate the patient.
(1) Disconnect ventilator tubing if patient is receiving mechanical ventilation.
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(2) Give the patient several breaths of 100 percent oxygen with the ambu bag and quickly
remove the bag.
Figure 3-4 Suction catheter and connecting tube.

j. With the suction diverted, gently insert the sterile suction catheter into the tracheostomy tube
until slight resistance is felt, then pull back slightly.
k. Apply suction.
(1) Place the thumb of your non-dominant (non-sterile) hand over the suction control port of the
catheter.
(2) Rotate the catheter between the thumb and index finger of your sterile hand while
withdrawing the catheter. Apply intermittent suction while withdrawing.
(3) Suction only for 5-10 seconds. Refer to Figure 3-5.
l. Instruct the assistant to hyper oxygenate the patient while you rinse the catheter by suctioning a
small amount of the sterile saline.
m. If secretions are thick, instill 5 cc of sterile normal saline into the tracheostomy tube and
suction again.
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Figure 3-5 Tracheostomy suctioning.
n. Repeat the suction procedure until the airway is clear.
(1) Hyper oxygenate the patient between suctioning.
(2) Rinse the catheter between suctioning.
o. Reconnect the patient to the ventilator if one is in use.

p. Perform oropharyngeal suctioning, if required.
q. Discard used equipment and restock the patient's bedside with new equipment.
r. Record the procedure in the Nursing Notes.
PERFORMING TRACHEOSTOMY CARE
Changing the tracheostomy dressing, cleansing the skin around the stoma, and cleaning the inner
cannula are collectively referred to as tracheostomy care.
a. Assemble necessary equipment and supplies.
(1) Trach cleaning kit (obtain from CMS).
(2) Clean scissors.
(3) Hydrogen peroxide.
(4) Sterile saline--pour bottle.
(5) Sterile gloves--2 pairs.
(6) Exam gloves--2.
(7) Waste receptacle.
b. Explain the procedure to the patient and establish a method of communication.
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c. If suctioning is required, perform that procedure prior to beginning tracheostomy care. It is
routine to perform tracheostomy care after suctioning.
d. Position the patient in semi-Fowler's position if permissible.
e. Wash your hands and set up the equipment using aseptic technique.
(1) Open the cleaning kit, using wrapper as a sterile field.
(2) Open dressings and other supplies and place on sterile field.
(3) Pour hydrogen peroxide in one basin and sterile saline in the other (disposable
basins/containers are included in the kit).
f. Put on exam gloves and remove soiled tracheostomy dressing. Tracheostomy secretions should
be considered contaminated and handled accordingly.
g. Remove and discard exam gloves and put on sterile gloves.
h. Clean inner cannula, if present.
(1) Unlock the inner cannula and remove.
(2) Place the inner cannula in the hydrogen peroxide, allowing it to soak for a few minutes.
(3) Clean the inner cannula with the test tube brush.
(4) Rinse the inner cannula in the sterile saline.
(5) Remove the inner cannula from the saline and allow it to drain on a sterile 4x4 gauze sponge.
i. Cleanse the tracheostomy incision and surrounding area with antiseptic swabs.
(1) If crusting occurs, remove with sterile swabs soaked in hydrogen peroxide.
(2) Do not allow cleansing solutions to enter the tracheostomy opening.
j. Reinsert the inner cannula and lock in place.

k. Apply sterile tracheostomy dressing. Use precut, non-raveling sterile 4x4. Place it with the slit
toward the chin, allowing the uncut portion to absorb secretions.
l. Reapply ties.
(1) Cut and remove soiled, outer tube ties if necessary. The patient or an assistant should hold the
outer tube in place to prevent dislodgement of the tube.
NOTE: If an assistant is not available and the ties must be changed, secure new ties in place
before cutting and removing soiled ties.
(2) Cut a slit about one inch from the end of each tape.
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(3) Insert the slit end of the tape through the flange of the outer cannula, and draw the other end
of the tape through the slit (Figure 3-6).
Figure 3-6 Tracheostomy dressing.

(4) Tie the tapes securely with a knot, never a bow. Position the knot at the side of the patient's
neck rather than the back. Trim off excess tape.
m. Remove and discard gloves or return all equipment to the appropriate location.
n. Record procedure in Nursing Notes.
CARE OF THE TRACHEOTOMY TUBE
Tracheotomy is an incision made into the trachea with insertion of a cannula for airway
management. A tracheotomy is performed for the patient with potential or present airway
obstruction for ventilator assistance; it can be a permanent or a temporary therapy. The patient
may have one of the three types of tracheotomy tube- metal, plastic and rubber, the metal tube is
used mainly for long term therapy and has three parts- an outer cannular, an inner cannular and
an obdurate that guides the insertion of the outer cannular. Tracheotomy care is performed
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frequently using aseptic techniques until the stoma is healed to prevent infection. Tracheotomy
care has the following goals:
 By ensuring airway patency and keeping the tube fee from mucous buildup.
 To maintain mucous membrane and skin integrity
 To prevent infection and
 To provide psychological support
Indications of tracheotomy care: excess, peristomal secretion, excess intratracheal secretions,

soiled or damp tracheotomy ties or dressing, diminished airflow through tracheotomy tube and
signs and symptoms of airway obstruction
Indication of tracheotomy: tumor of the larynx, oedema of the larynx and foreign body
blocking the trachea.
REQUIREMENTS
Hydrogen perioxide, normal saline, disposable and sterile gloves, 2 sterile gallipots, sterile
gauze, items for suctioning and month care 2 sterile solution containers.
PROCEDURE
1. Explain procedure and the rational to patient and gain his cooperation and provide privacy.
2. Prepare trolley aseptically and send to the bedside.
3. Place the patient into supine or semi-fowlers position unless is contraindicated.
4. Wear disposable glove and suction the entire length of the tracheotomy tube.
5. Remove the inner tube by turning the lock about 90 counter clockwise with the dominant hand
and the non dominant hand remove the inner cannular by gently pulling it out.
6. Soak the inner cannular in hydrogen peroxide for several minutes and suction the outer
cannular.
7. Remove glove, wash hands put on sterile gloves.
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8. Remove inner tube from hydrogen solution into the sterile bowl with saline solution and brush
the lumen and entire inner canula thoroughly.
9. Rinse the inner tube in a clean saline solution and dry the inner side of canula with gauze
squares twisted together.
10. Re-insert inner canula into outer canula
11. Clean the stoma in a circular direction away from the stoma site using square gauze on
forceps or with sterile cotton bunds with saline solution. If there are debris, clean with hydrogen
peroxide before saline solution.
12. Apply a sterile dressing and change the tie tapes, check tightness of tracheotomy tie.
13. Make the patient comfortable and assess the respiratory status
14. Thank patient, discard and decontaminate equipment
Document the following: respiratory status before and after the procedure, the type and size of
tracheotomy tube, frequently and extent of care, and patient’s tolerance, observe.
Soiled dressing and any suctioned secretions for amount, colour consistency and odor, stoma and
skin condition.
Complications: haemorrhage, oedema within tracheal tissues, causing airway obstruction,

aspiration of secretions, pneumothorax, hypoxia and wound infection.
SUCTIONING
Oronasophryngeal suctioning is the removal of secretions from the pharynx by means of a

suction catheter inserted through the month or nostril for maintenance of a patent airway.
Indications: patients who are not able to clear their airway effectively, unconscious or severely
debilitated patients, incubated patients, vomitus in the mouth, head, and chest and neck tumours
EQUIPMENTS: suction catheter, clean and sterile gloves, clean towel, suction machine,
connecting tubing, lubricant, sterile basin and normal saline,
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PROCEDURE
 Explain the procedure to the patient and the reasons and reassure him or her throughout the
procedure.
 Check the need of the patient to be oxygenated
 Check patient vital signs and record
 Evaluate the patient ability to cough and deep breathe
 Check the patient history of a deviated septum, nasal polyps or obstruction epistasis and
mucosal swelling.
 Send items to the patient bed side-Attach the collection bottle to the suctioning unit and
attach the the connecting tubing to it and open the bottle of normal saline or sterile water.
 Wash your hands
 Place the patient in a semi-fowlers or high fowlers’ position if tolerated, protect the chest
with a clean towel.
 Turn on the suction from the wall and set the pressure usually between 80mm and 120 mm
Hg.
 Using aseptic technique, open the suction catheter and put on gloves using the non sterile
hand to pour normal saline in the sterile container.
 Use the non sterile hand and place a small amount of lubricant on the sterile area.
 Pick up the catheter with the sterile hand and attach it to the connecting tubing.
 Control the suction valve with the non sterile hand and the catheter with your sterile hand.
 Encourage the patient to cough and breathe slowly deeply several times before beginning
suction or the unconscious patient should be hyper oxygenated.
 For nasal insertion, without applying suction, raise the tip of the patient nose and insert
catheter into the patient nares and roll the catheter between the figures, advance to about 5 to 6
inches until the patient coughs.
 For oral insertion, without applying suction, gently insert the catheter into the patient’s
month for about 3 to 4 inches along the side of the patient month until the patient coughs
suction both side of the month and pharyngeal area.
 Apply intermittent suction for about 10 to 15 seconds, withdraw the catheter from the nose
and mouth with a continous rotating it back and forth between sterile thumb and fore finger.
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 If secretions are thick clear the lumen of the catheter by dipping it into water and applying
suction.
 Repeat the procedure until bubbling or gurgling sounds stop and respirations are quiet
 After suctioning, remove towel and gloves and discard the item and flush the connecting
tubing with sterile water.
 Wash your hands and make patient comfortable and provide oral hygiene as needed.
 Record the amount, constituency, colour and odour of the secretions, patient responses to
suctioning, the patient respiratory status before and after the procedure and any complications
and any actions taken.
Complications: hypoxemia, laryngeal spasms, nasal trauma and bleeding.
POSTURAL DRAINAGE EXERCISE
This is the use of specific positions to drain by gravity secretions from the various lung segments
into the major bronchi or trachea; it is done for patient with cystic fibrosis, patient with large
amount of sputum and bronchiecstais.
Uses
 To remove secretions that have been accumulated in the lungs of patient who have chronic
lung disease or other respiratory problems.
 To prevent accumulation of secretions in the unconscious patient.
PROCEDURE
1. The patient may be given bronchodilators which would help to promote drainage and
expectoration.
2. The patient must be told to cooperate during the procedure.
3. Postural drainage is scheduled for 2 or 3 times daily depending of how congested the lung is.
The best times are before meals or 1 hour 30mins after meals because if it is done soon after
meals it can cause nausea and vomiting leading to aspiration.
4. The entire procedure includes preparation with bronchiole dilators and postures and takes
about 30mins; some patients can tolerate the procedure for long hours whiles others cannot.
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5. Percussion and vibration of the chest wall are methods employed to drain dry tenacious
secretion during postural drainage exercise.
6. Percussion is a technique of using the cupped hands to strike forcefully the chest wall over
the congested area. The hands and figures are held together and slightly
Flexed to form a cup such as one formed when scooping water with the hands. Percuss each
segment for 1 or 2mins by alternating the hands. During percussion striking the spinal column,
breast and the kidney should be avoided.
7. Vibration is a technique of using the fingers and the palm of the hands against the chest wall.
Vibrate during five exhalations over each chest segment.
8. The patient is encouraged to cough up secretion into a tissue or sputum mug.
9. If possible perform suction.
NOTES:
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CHAPTER FOUR
BARIUM MEAL
Is the ingestion of thick suspension called barium for the purpose of visualizing the upper G.I.T.
after which series of x-rays are taken and filmed
Indications: ulcers, tumours, esophageal stricture, carcinoma, pyloric stenosis and detection of
structural abnormalities like inflammation of the esophagus, stomach and duodenum.
Nursing implication
 The barium meal procedure taken 20-30minuts.

 Get a written instructions about the preparation of the patient from the x-ray technician
 Consent from should be signed by the patients
 A minimum fasting of 6 hours is required.
 Before the examination, the patient should be given some laxatives at bed time for two
nights.
 The procedure should be thoroughly explained to be patient regarding time, taste of barium
meal and why the procedure is required.
 The patient should wear a gown and remove all metallic objects coming in exposure area.
 During examination patient has to lie down and x-ray is taken at intervals of 3minutes for 3
to 4 hours. Or in series for about 30minis.
 The nurse should tell the patient that the table may be tiled up and down during procedure
 After procedure the patient should be asked to take normal food & drinks.
 The nurse should ensure complete evacuation of barium-meal in stool
 She should tell patient that the stool may be paler in colour & there may be constipation.
 The nurse should observe the patient for any epigastria pain or discomfort.
 The nurse should intimate doctor if the patient does not pass stool for 2-3 days.
 Encourage patient to take at least 2litres of water after the procedure.
BARIUM SWALLOW
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Barium swallow is given orally to outline the esophagus and the upper part of the stomach for
any abnormalities such as esophageal stricture, carcinoma, diverticulitis haital hermia etc.
BARIUM- ENEMA
Procedure:
The procedure consists of introduction of barium sulphate solution into colon slowly by rectal
tube and the filling process is observed by fluoroscopy and x-ray films.
It takes about 30minutes.
Purpose
Useful to detect structural abnormality such as polyp, diverticulitis, abnormal mass, stricture,
obstruction and ulcerating in large bowel
Nursing Implication
 The procedure and its purpose are explained to the patient.

 Patient is fasted from midnight for between 6- 8 hrs
 Consent form is signed by the patients
 A low residual diet is given to patient for 36-48 hours before examinations.
 A cleansing enema is given the evening before the investigation to be done in morning.
 A high colonic wash=- out is done not less that 4 hours before x-ray examination.
 Out- patients are advised on diet and oral laxatives and a suppository is given in the morning
of examination.
 The patient is asked to undress completely and to wear one gown.
 The patient is put on left-lateral position on x-ray table.
 Privacy should be maintained.
 The patient should be told that the procedure is uncomfortable but not painful.
 The discomfort can be reduced by taking deep breath
 After procedure the patient should rest comfortably, should eat and drink normally.
 He should be told by the nurse that stool will look pale.
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 Just after the procedure the patient should be encourage to go for toilet to evacuate barium
and air.
 Absence of stool for 2-3 days should be reported to doctor.
 Encourage patient to take at least 2 litres of water after the procedure.
ENDOSCOPY
This is an investigation consisting of visualizing upper gastrointestinal tract by means of a

flexible optic instrument. This procedure is done under local anesthesia by gastroenterologist. It
takes about 20-30 minutes.
Purpose
To examine esophagus, stomach and duodenum for tumours, varices, polyps, ulcers,
obstructions, foreign bodies of the upper GIT, hiatus hernia and other mucosal patterns. Its takes
about 20-30minutes.
Types
 Gastroscopy
 Oesophagosgopy
 Oephagogastroduodenoscopy
 Gastroduodenojejenoscopy
Nursing Implications
 The procedure and purpose is explained to the patient.

 A consent form is signed by the patient
 Metallic objects are removed from neck up to waist line
 Routinely a gown is put on by the patient
 Stomach is emptied prior to investigation by gastric lavage
 A minimum fasting of 8 hours is done.
 Remove dentures or any other dental appliances
 Perform health assessment for the patient to find out if the patient has DM.
 Assess whether the patient is on NSAID for the last 5 days
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 In urgency where fasting is not done gastric lavage is to be done to empty stomach content.
 Allow the patient to empty bladder before and after procedure
 A muscle relaxant (injection or oral) is prescribed by gastroenterologist.
 Atropine may be administered to reduce secretions.
 A local anesthesia in form of a spray is used to facilitate introduction of endoscope
 The effects of local or general anesthesia should be explained to the patient.
 Maintain oral hygiene before and after the procedure.
 The patient is positioned in the left lateral position to facilitate clearance of pulmonary
secretion and provide smooth entry of the scope.
 Check the patients gag reflex which usually returns 2- 4- hours after procedure.
 Throat lozenges, saline garle and analgesics should be given to overcome discomfort and the
hoarseness of the voice
 After the procedure monitors the patient level of consciousness, and sign for perforation
(pain, bleeding and unusual difficulty in swallowing) at least half hourly until the condition is
stable.
 The patient should be informed that he may have sore- throat for several days after the
procedure.
 Regular gargling should be ensured a cold fluid or drinks should be encouraged.
 Check vital signs every 15mins initially until the patient condition is stable.
PROCTOSCOPY AND SIGMOIDOSCOPY (protosigmoidoscopy)
Procedure
The procedure consists of viewing of anum, rectum & sigmoid colon by using proctoscopy and
sigmoidoscopy introduced through anus.
Purpose
Procto- sigmoidocopy is performed to examine the rectum and distal part of sigmoid colon, piles,
polyps, fistula, abscess, tumours, ulcers & infection of the lower GIT as well as the biopsy of the
rectum.
REQUIREMENTS
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An illuminated protoscopy, gauze swabs, paper bag for used swabs, lubricant, gloves and a
fenestrated drape.
Nursing Implication
 The procedure & purpose is explained to the patient.

 The rectum is evacuated by enama or suppository before examination.
 The nurse must ensure that the patient has taken a clear diet 2 days before the procedure.
 Privacy should be maintained throughout the period of the procedure
 The patient should lie in left lateral position with the knees drawn up to the chest and the
buttocks just over side of the bed this provides a clearer view of the sigmoid colon.
 A consent form is signed
 The protoscopy or sigmoidoscopy is cleaned & boiled or autoclaved and made cool &
lubricated before introduction.
 The patient is encouraged to breathe deeply & slowly and try to relax during insertion.
 Air is introduced into the colon so that a clear field of vision in obtained and patient is
informed that this will make him pass excessive flatus.
 After procedure the patient is allowed to rest & later encourage for normal activities.
 Biopsy can be taking by this procedure in which case there may be mild bleeding in the
patient stool.
 Wash and discard the instrument and sterilize those that need to be sterilized.
 Documents the procedure
Complications: abdominal distention and peritonitis.
LAPAROSCOPY
This consists of direct viewing of abdominal and pelvic organs by means of a long fiberoptic
instrument (laparoscope) inserted through the abdominal wall.
The procedure is done to diagnose:
1. Pelvic adhesions
2. Ovarian cysts
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3. Tumours and other causes of infertility
4. for tubal ligation as a family planning procedure
Nursing Implications
1. The procedure and the purpose is explained to the patient
2. And enema or laxative is given to the patient the night before the procedure
3. The abdominal wall is shaved from the umbilicus and upper pubic region
4. Bath is encouraged in the morning of the procedure
5. The procedure can be done under local or general anesthesia
6. The patient is asked to pass urine
7. Instruct patient to remove metallic objects from the body especially on the abdomen and waist.
8. Gown the patient with a cotton material
9. Pre-medication is given 1 hour before the procedure.
10. The patient is positioned either in Trendelenberg or lithotomic position
11. 3-4 litres of gas (Carbondioxide) is introduced through a small incision below umbilicus for
abdominal distension and clear visualization of organs.
12. After the procedure, all routine post-operative care should be adopted by the nurse especially
in general anesthesia cases
13. Perineal toileting is done regularly
14. Maintain fluid intake and output
15. Observation is made for any signs of perforation such as shock
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16. Check vital signs and record 15mins for an hour, 30mins for 2hours and hourly as the
condition remains stable
17. The incision site should be observed for bleeding and hematoma
18. Document the procedure.
LIVER BIOPSY
The procedure consists of insertion of a special liver biopsy needle through skin either at lower
part of thorax or through abdominal wall to the liver. The patient lies on his back as near the rite
side of the bed as possible. The right arm is supported above his head to provide clear access to
the right intercostals space. The needle is introduced into the mid or anterior maxillary line
between 8th or 9th and 10th ribs.
A piece of liver tissue is aspirated for the laboratory examination. Prior to procedure bleeding
time, clotting time and platelet counts are done. Blood grouping is also done for blood
transfusion if required. In case of any bleeding, tendency injection vit. K is given.
Purpose
For diagnosis of liver disorders like cirrhosis, hepatitis, tumours of the liver and drug reaction.
Requirement: a gallipot with sterile swabs, antiseptic lotion, aspiratin needle, anesthetic agent,
needles and syringes, adhesive plaster, specimen bottle, vital signs tray, mackintosh and sterile
dressing towel, sterile gloves.
Nursing Implication
 The procedure and purpose is explained to the patient and reassurance is given to remove
any fear for the procedure.
 Consent form is signed by the patent
 The patient is kept fasted for 6 hours
 Vital signs are checked and recorded
 Premedication such as diazepam is also given
 The patient is asked to undress up to waist line.
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 The skin is prepared aseptically
 Position is maintained either of supine or of left lateral and supported with pillows
 A sterile pressure dressing is applied after the procedure at the puncture site.
 The patient is asked to lie on right or the affected site and supported with pillows for at
least 2 hours.
 He is asked to rest for 12 hours
 In more apprehensive patient BP and pulse is taken at intervals, every 30mins until the
condition is stable.
 For pain some analgesics can be given as prescribed
 In case of internal bleeding from liver, BP and pulse record will indicate the attention of a
doctor.
 Decontaminate, wash and discard the instruments also make patients comfortable in bed
 Documentation: date, time and site of the liver biopsy, the patient tolerance of the
procedure, vital signs before and after and any bleeding oberserved.
Complication: perforation of the portal and hepatic veins, laceration of the liver, pneumothorax,
and perforation of the gall bladder.
Paracentesis Abdominis
The abdomen usually contains a minimal amount of fluid, in certain disease conditions fluid can
accumulate in the abdominal cavity. Paracentesis (abdominal tap) is a sterile procedure in which
a needle is inserted through the abdominal wall into the peritoneal cavity to obtain a sample of
any fluid that is present or to drain a large volume of fluid to relive pressure on the diaphragm.
Indications: infections o f the abdomen, tumour, appendicitis, cirrhosis of the liver, diseases of
the pan crease, heart e.g. CCF, kidney e.g. nephritis and nephritic syndrome, damaged of the
bowel and abdominal trauma.
REQUIREMENTS
A sterile trolley with the following;
Antiseptic lotion, canula, syringe and needle, Xylocaine, sterile specimen bottle, giving set,
drainage bag or bottle adhesive tape, surgical gloves, 50ml syringe and sterile cotton wool,
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mackintosh and sterile dressing towel, hypothermic syringe and needle and abdominal binder
paracentesis abdomins set containing forceps, scapel blade and the holder, swabs, towels,
suturing marerilas , trocar and canula, rubber tubing.
Resuscitation tray, tape measure, vital signs tray containing thermometer, stethoscope,
sphygmomanometer intake and output chart, ruler, gallpot for swabs. Dressing pack and
weighing scale.
BEFORE THE PROCEDURE
 Explain the need for the procedure to the patient

 Ensure that consent has been signed
 Check and record vital signs specially blood pressure and record
 Have patient void before the procedure or catheterize if he cannot pass urine
 Ensure that the patient has emptied the bowel
 Check patients weight and record
 Apply abdominal binder to the abdomen before and after the procedure distribute the fluid
evenly evenly in the abdomen.
 Assess the abdomen and measure abdominal girth at the higher point of the abdomen.
 Set sterile trolley and sent to patient’s bed side or treatment room
 Shave patient abdominal wall, wash with soap and water clean with an antiseptic lotion and
cover with a sterile dressing towel or drape.
 Bath patient or ask patient to go and bath
 During the procedure
 Ensure that the patient assumes the desired position; semi fowlers in bed,sitting upright on
the side of the bed or on a chair with feet supported,
 Wash your hands and set up trolley.
 Assist the physician throughout the procedure, the doctor cleans the area with antiseptic
lotion, local anesthesia is injected for some time and the needle is introduced between the
umbilicus and the symphysis pubis to drain the fluid into a receptacle
 Reassure patient throughout procedure.
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 Check vital sign every 15minutes during the procedure.
 After the procedure
 Pressure dressing is applied to the site
 Check vital signs every 15mins for 1 hour and then every 30mins for 2 hours and record as
the condition remains stable.
 Monitor urinary output for signs of bleeding for 24hours
 Observe dressing over the insertion site for signs of bleeding or leakage of fluid
 Measure the abdominal girth and weigh the patient
 Apply abdominal binder to the abdomen before and after the procedure to distribute the fluid
evenly in the abdomen. Tighten binder when fluid stars flowing.
 Observe the characteristic of the aspirate and record
 Do not withdraw more than 2litres of ascetic fluid
 Observe the signs and symptoms of shock
 Assess the pain level of the patient and serve the prescribe analgesic
 Monitor intake and output
 Label the specimen and send to the lab with the request form
 Decontaminate the used items.
 Document the following
 Time of procedure, purpose, colour consistency and the amount of fluid drained patient’s
tolerance of the procedure and if there is any changes is the abdominal girth, weight and vital
signs. Whether the patient complains of severe abdominal pain and if there is bloody
drainage form the insertion site.
Complication: puncture of the bladder, bowel and blood vessels in the abdomen, hypovolemic
shock and peritonitis.
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CHAPTER FIVE
PASSING OF NG TUBE
If the patient is unable to swallow due to e.g. paralysis of the soft palate, or unconsciousness or
semi-conscious or unable to consume sufficient nutrition orally, he may be fed artificially using a
tube nasally down the esophagus into the stomach, for decompression of gastric content before
and after G. I. T. surgery, to obtain gastric specimen for diagnosis purpose, for lavage after
poison intake and to estimate the amount of bleeding in the stomach.
REQUIREMENTS
A tray with the following:-
A receiver with a sinus forceps (or orange stick covered with cotton wool swabs or cotton wool
buds) for cleaning the nostrils
Ryles tube or NG tube
Disposable syringe barrel 20-50cc or extra rubber tubing, glass connection and a glass funnel.
A gallipot containing lubricant e.g. liquid paraffin, A gallipot with wool swabs Graduated glass
with 30 mls of water, Receiver for used swabs
Litmus paper to test aspirate in order to ascertain position of the tip of the tube Adhesive
strapping, A pair of scissors, Jaconet cape and cover.
PROCEDURE
1. Explain procedure and the reason to patient

2. Provide privacy to enhance the patient’s dignity
3. Send prepared tray to the bedside and place it on the patient’s locker
4. Wash and dry hands
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5. Determine the patency of the nares. Tell patient to close each nostril alternately and breath.
Examine each naris for patency and skin breakdown.
6. Review the patient medical history: bleeding, facial trauma, nasal surgery and anticoagulant
therapy.
7. Make patient comfortable in a suitable position e.g. conscious patient is put in the high-
fowlers and unconscious patient is placed in the patient semi- fowlers position.
8. Place jaconet cape and cover across the patient’s chest, to protect clothing.
9. Clean patient’s nostrils to provide clean passage and have patient blow the nose
10. Note marking on the tube to determine the approximate distance of 50-60cm from the
stomach end of the tube (or measure the distance from the tip of the nose through the lobe of
the ear to the xiphoid process of the sternum and mark the point with a pencil on the catheter.
11. Determine which nostril will allow for easier access.
12. Lubricate the tip of tube with lubricant.
13. Insert tube gently but quickly, passing if backwards and downwards.
14. Look into patient’s mouth to make sure tube has not coiled up in the mouth.
15. Ask patient to swallow if conscious
16. Check if gastric tube is in stomach by the following:_
(a)Aspirating a small amount of gastric juice and checking acidity with litmus paper
(b) Observing if patient is cyanosed
(c) Note if he is coughing
17. Pinch the tube and spigot the end, strap it to patient’s cheek
18. Make patient comfortable
19. Remove screen, discard tray and wash hands
20. Document the following; the size of tube inserted, the nares used, how the patient tolerated
the procedure, the method used to verify the placement, the characteristics of the aspirate and
the amount of gastric content aspirated.
How to cheek for NG tube placement
1. Inject 10mls of air through the tube and auscultator over the left upper quadrant of the
epigastria region of the abdomen. And listen to the whooshing sound.
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2. X-ray confirmation.
3. Signs and symptoms of airway obstruction such as cough cyanosis, restlessness and tears from
the eyes.
4. Inject 5cc of air into the tube and aspirate the stomach content and test with the litmus paper.
A ph below 5 is a gastric juice and a ph above 6 is an intestinal juice.
5. Another method is: connect the external end of the tube into a bowl of water then it is
observed for air bubbles, if air bubbles come out it means the tube is in the air passage. But this
method is controversial because if the tube is in respiratory tract while testing it means some
water will be sucked into the air passage.
Complication of prolonged intubation: nasal erosion, nasopharyngeal ulcer, sinusitis, otitis,

esophagitis and vocal cord paralysis.
FEEDING A PATIENT PER NASO- GASTRIC TUBE/GASTRIC GAVAGE
Enteral nutrition is the administration of nutrients directly into the G. I. T. The most desirable
and appropriate method of proving nutrition is the oral route. Unfortunately this is not always
possible. When oral feedings are not possible, yet the stomach and the intestines are able to
function properly the enteral tube feeding is an alternative. Enteral tube feeding is preferred over
parenteral nutrition because it improves utilization of nutrients, is generally safer for patients,
maintains structure and functions of the gut and is less expensive.
INDICATIONS:
 Paralysis of the pharyngeal muscles, (impaired swallowing or gag reflex which is related to a
neurological problem eg patient with stroke)
 Nutritional deficit due to reduced food intake.(patient with cancer, sepsis, burns and trauma)
 Operations of the mouth, pharynx, head and neck
 Premature and weak baby who are not able to suck
 Insanity where the patient is refusing to eat
 Unconscious patient for more than 24 hours
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REQUIREMENTS
A tray containing the following items:
A graduated jug (the size depends on the amount of feed ordered) containing the feed e.g.
complain, diluted milk, custard and strained soup, tea and porridge. Jaconet cape and cover,
stethoscope, litmus paper.
Disposable syringe barrel 20-50cc and Mouth wash to rinse after the feed.
Principles of tube feeding
1. The tube should not be coiled in the mouth or passed into the lungs
2. Tube should be warmed to the body temperature before given to stimulation of the stomach
nerves.
3. Air should not be allowed to enter the stomach
4. Feed should be given slowly to avoid stomach distention and stimulation of stomach nerving
endings.
5. NG tube should be changed at least every 7 days to prevent tissue reaction.
PROCEDURE
 Explain procedure to patient and provide privacy

 Send prepare feed in a tray to the patient’s bedside
 Make patient assume semi-fowlers position and protect patient’s clothing.
 Check for proper placement of tube in the stomach by pushing 5cc of air in to the NG tube
aspirating the stomach content and testing for acidity (PH) using Litmus paper
 OR inject 10-30cm of air through the tube an auscultate over the left upper quadrant of the
epigastria region with a stethoscope and listen to the whooshing sound simultaneously
indicating proper positioning of the tube.
 Wash and dry hands.
 Check temperature of feed by dropping a little amount on the back of hand.
 Pinch tube and remove spigot of Naso- Gastric tube, push 10-15mls of
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 Water through the tube just before feed is introduced to ensure the patency of the tube.
 Pinch the proximal end of the feeding tube, remove the plunger from the syringe and connect
the barrel of the syringe to the feeding tube
 Fill syringe with the feed, release the pinch, elevate syringe above the insertion site and allow
the feed to run by gravity.
 Ensure the tube is never allowed to empty completely to prevent air from entering patient’s
stomach.
 Continue feeding till feed is finished
 Flush the tube with 10-15mls of water at end of feeding
 Pinch tube, remove syringe and replace spigot
 Let the patient remain in this position for about 30mins to prevent aspiration pneumonia.
 Remove protective clothing, and make patient comfortable, discards tray,
 Wash and dry hands.
 Document procedure on intake and output and nurse note; method of verification of tube
placement, the colour of any aspirate and the PH if it was tested and the patient’s tolerance of
the feeding.
Complication of tube feeding: pulmonary aspiration leading to aspiration pneumonia, electrolyte

alterations, hyperglycemia.
ASPIRATION
Aspiration (the misdirection of oropharyngeal secretions or gastric contents into the larynx and
lower respiratory tract) is common in older adults with dysphagia and can lead to aspiration
pneumonia. In fact, it has been suggested that dysphagia carries a sevenfold increased risk of
aspiration pneumonia and is an independent predictor of mortality (Singh & Hamdy, 2006).
Early recognition of dysphagia and intervention in hospitalized patients is advised to reduce
morbidity and use of hospital resources (Altman et al., 2010).
TARGET POPULATION: Dysphagia is common in persons with neurologic diseases such as

stroke, Parkinson’s disease, and dementia. Aspiration occurs in about 40% to 50% of stroke
patients with dysphagia (Marik & Kaplan, 2003). The older adult with one of these conditions is
at even greater risk for aspiration because the dysphagia is superimposed on the slowed
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swallowing rate associated with normal aging. Conditions that suppress the cough reflex (such as
sedation) further increase the risk for aspiration.
BEST PRACTICES: ASSESSMENT AND PREVENTION ASSESSMENT

Videofluoroscopy is considered the gold standard to study the mechanisms of dysphagia; if
unavailable, fiberoptic endoscopic evaluation may be used instead (Rofes et al., 2011). Others
recommend these tests only for patients who fail a reliable clinical swallowing assessment
(Leder et al., 2012)
Clinical Symptoms of Aspiration:
• Sudden appearance of respiratory symptoms (such as severe coughing and cyanosis)
associated with eating, drinking, or regurgitation of gastric contents.
• A voice change (such as hoarseness or a gurgling noise) after swallowing.
• Small-volume aspirations that produce no overt symptoms are common and are often not
discovered until the condition progresses to aspiration pneumonia.
Aspiration Pneumonia:
• Older persons with pneumonia often complain of significantly fewer symptoms than their
younger counterparts; for this reason, aspiration pneumonia is under-diagnosed in this group.
• Delirium may be the only manifestation of pneumonia in elderly persons.
• An elevated respiratory rate is often an early clue to pneumonia in older adults; other
symptoms to observe for include fever, chills, pleuritic chest pain and crackles.
• Observation for aspiration pneumonia should be ongoing in high-risk persons.
PREVENTION OF ASPIRATION DURING HAND FEEDING:

The following actions may be of some benefit during hand feeding:
• Provide a 30-minute rest period prior to feeding time; a rested person will likely have less
difficulty swallowing.
• Sit the person upright in a chair; if confined to bed, elevate the backrest to a 90-degree angle.
• The chin-down or chin-tuck maneuver is widely used in dysphagia treatment, although it
does not have a precise anatomical definition (Okada et al., 2007). The extent to which this
maneuver is effective is unclear. A recent study of 47 patients with a videofluoroscopic
diagnosis of aspiration found only 55% avoided aspiration during the chin-down posture
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(Terre & Mearin, 2012).Swallowing studies may be needed to determine which individuals are
most likely to benefit from this position.
• Adjust rate of feeding and size of bites to the person’s tolerance; avoid rushed or forced
feeding.
• Alternate solid and liquid boluses.
• Vary placement of food in the person’s mouth according to the type of deficit. For example,
food may be placed on the right side of the mouth if left facial weakness is present.
• Determine the food viscosity that is best tolerated by the individual. For example, some
persons swallow thickened liquids more easily than thin liquids. However, a recent study
found that even in known thin liquid aspirators, offering water did not increase the incidence
of aspiration pneumonia (Frey & Ramsberger, 2011).
• Be aware that some patients may find thickened liquids unpalatable and thus drink
insufficient fluids (Colodny, 2005).
• Minimize the use of sedatives and hypnotics since these agents may impair the cough reflex
and swallowing.
• Medications that dry up secretions should be avoided since they make it more difficult for
patients to swallow (Marik, 2011).
• Evaluate the effectiveness of cueing, redirection, task segmentation and environmental
modifications (minimizing distractions) as alternatives to hand feeding.
PREVENTION OF ASPIRATION DURING TUBE FEEDING:
Tube feeding is not necessary for all patients who aspirate (Marik, 2011). However, short-term
tube feeding may be needed for elderly patients with severe dysphagia and aspiration in whom
improvement of swallowing is likely to occur (Marik, 2011). Results from a clinical trial suggest
that patients with dysphagic stroke should be fed early by nasogastric tube and then transitioned
to oral feeding as their dysphagia resolves (Dennis et al., 2005). Patients whose dysphagia does
not resolve may ultimately require placement of a percutaneous gastrostomy tube.
For patients with tube feedings, the following considerations are important:
• Keep the bed’s backrest elevated to at least 30º during continuous feedings.
• When the tube-fed person is able to communicate, ask if any of the following signs of
gastrointestinal intolerance are present: nausea, feeling of fullness, abdominal pain or
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cramping. These signs are indicative of slowed gastric emptying that may, in turn, increase the
probability for regurgitation and aspiration of gastric contents.
• Measure gastric residual volumes every 4 to 6 hours during continuous feedings and
immediately before each intermittent feeding. This assessment is especially important when
the tube-fed person is unable to communicate signs of gastrointestinal intolerance. There is no
convincing research-based information regarding how much gastric residual volume is ‘too
much.’
• Use of a promotility agent should be considered when an adult patient has two or more
gastric residual volumes ≥ 250 ml (Bankhead et al., 2009).
• The incidence of pneumonia is not different in patients with nasogastric tubes and
percutaneous endoscopic tubes (Gomes et al., 2010). However, a gastrostomy tube is more
comfortable for the patient than is prolonged use of a nasogastric tube.
PREVENTION OF ASPIRATION PNEUMONIA BY ORAL CARE:
Missing teeth and poorly fitted dentures predispose to aspiration by interfering with chewing and
swallowing. Infected teeth and poor oral hygiene predispose to pneumonia following the
aspiration of contaminated oral secretions. Tube feeding in elderly persons is associated with
significant pathogenic colonization of the mouth, more so than that observed in those who
received oral feedings.
There is evidence that providing regular dental care and cleaning the elder person’s teeth with a
toothbrush after each meal lowers the risk of aspiration pneumonia. Development and
maintenance of an oral hygiene program is a critical step in preventing pneumonia in nursing
home residents (El-Solh, 2011).
GASTROSTOMY FEEDINGS AND JEUNOSTOMY FEEDING
Gastrostomy feeding means an artificial opening into the stomach through the abdominal wall
into the intestines for the purpose of feeding.
It is usually performed when there is a permanent obstruction of the oesophagus or when there is
severe injury to the esophagus, esophageal atresia and obstruction
REQUIREMENTS
A tray containing the following:-
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A piece of rubber tubing, Adaptor/tubing connection/20ml-50ml syringe Catheter (if gastrostomy
tube has been removed and the opening closed by gasrostomy plug)
Dressing mackintosh and towel, A glass of water, Funnel barrier creams, fluid diet, measuring
cup, napkin gloves and plastic apron
PROCEDURE
The tray must be attractive and if possible the patient must be given a little to taste.
1. Explain in procedure to the patient and provide privacy
2. Place the patient into a semi-fowlers position and turn bed clothes as far back as necessary
3. Place mackintosh and towel under the patient to protect the bed clothes
5. Remove the spigot from the catheter of if catheter has been removed, take the gastrostomy
plug out and insert the catheter required for feeding into the opening
6. Fix the end the connector to the catheter in the gastrostomy opening
7. Connect the rubber to the catheter by the connector.
10. A spirate gastric content to determine the amount of gastric residual and record aspirate, to
prevent the danger of gastric dilatation.
11. Connect funnel to rubber tubing.
12. Give the feed slowly through the funnel
13. Run water through to rinse catheter to prevent it from blocking
14. Remove the connector tubing and funnel and replace spigot or gastrostomy plug
15. Give mouth wash repeat every 4 hours
16. Observe the skin for break down, excoriation, irritations
17. Apply a clean protective silicon cream or Vaseline or zinc oxide ointment around the
gastrostomy opening twice daily and whenever spillage occurs during feeding
18. Remove mackintosh and towel and place patient into comfortable position.
19. Remove screen and discard tray
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20. Wash, dry hands and make patient comfortable
21. Maintain strict intake and output.
22. Maintain the position for 30mins after feeding to prevent regurgitation of the feed in the
esophagus and leakage around the catheter insertion site.
23. Document on the nurses note/fluid chart, date formula and the amount of feeding, the amount
of gastric residual that was aspirated, the method of tube placement that was used, if the
dressing at the tube insertion site was changed and the condition of the skin; brake-down,
irrigation and drainage, not any complaints of the patient such as abdominal distention,
nausea, vomiting, diarrhea and constipation.
24. Weight patient daily, then 3times per week. Monitor intake and output at least every 8 hours
and blood glucose level 6 hours also observe the patient for abdominal discomfort.
FRACTIONAL TEST MEAL FOR GASTRIC TEST MEAL
This test is done to amount of hydrochloric acid in the gastric juice and to assess the reaction of
the stomach to food.
Indications; Gastric ulcer, chronic or prolong indigestion, cancer of the stomach and pernicious
anaemia
Preparation
1. Explain procedure to patient to gain his co-operation

2. Fast patient overnight (at least 12 hours)
Equipment needed
A tray for passing a naso-gastric tube
A rack of test tubes as specified by laboratory technician (12 or 13 test tubes)
A measuring jug for resting juice, Litmus paper- blue and red
Two gallipots one with swabs, Receiver, vomit bowl, Mouth wash syringes and needles, Alcohol
7% 50mls
Cup and saucer on tray with gruel, oat meal, strained akasa
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Histamine 0.5mgs in syringe if ordered
PROCEDURE
1. Inform and explain the procedure, reassure patient and provide privacy
2. Patient is fasted for 12 hours before the procedure starts in the morning.
3. Put patient into the upright position
4. Place a towel across the chest of the patient
5. Pass the naso-gastric tube and secure to the cheek firmly by strapping
6. Aspirate all gastric contents that can be obtained and put it in a jug. Test with litmus paper and
note the colour change. Label this as the ‘resting juice’ or fasting specimen
7. Give the feed. If cereal meal is used it is given in a cup for the patient to drink. If alcohol is
used it is passed through the NG tube. Do not give the alcohol to the patient to drink
8. Spigot the open end of the nasogastric tube
9. Settle patient comfortably with a book or any recreational material until it is time to take the
next specimen. Or engage the patient by asking him/her to keep the time.
10. Withdrawn not more than 5mls of gastric juice at 20-30 minutes intervals into separate test
tubes.
11. Label each test tube with the number and time(2nd,3rd, 4th, 5th and 6th )
12. Test the 1st and 2nd withdraw gastric juice with litmus paper for acidity. If no acid is found
sub-cutaneous 0.5mgs histamine may be ordered before the withdrawal of the rest of the
specimens to stimulate the secretion of the gastric juice.
13. Any reaction to histamine such as severe headache may be relieved by anti histamine drugs
e.g. Piriton.
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14. After collection the desired number of the samples, the last juice aspirated is marked
’Residual juice’ or “Residence content”
15. Remove strapping, pinch tube and withdraw gently but bleakly and reassure the patient
16. Give patient a mouth wash, encourage him to take his breakfast and make him comfortable in
bed.
17. Ensure all specimens are sent to the laboratory for analysis with the request form.
18. Decontaminate, wash or discard equipments
19. Document all the finding and the patient reaction to the procedure
GASTRIC LAVAGE OR WASHOUT
It is the washing out of the stomach with normal saline or sterile water. In this procedure an NG
tube is passed nasally or orally into the stomach.
Objectives
To render the stomach clear from any content prior to stomach or duodenal surgery
To relieve patient of irritation from poisoning
To obtain sample for diagnostic purposes
To relieve severe nausea and vomiting
To clean the stomach post operatively to prevent stomach dilatation
REQUIREMENTS: sterile NG tube, lubricant, gloves, galipot with cotton wool swabs, the
solution- normal saline or sterile water, drip stand, receptacle, protective clothing funnel,
adhesive tape, 50ml syringe and a specimen bottle.
PROCEDURE
1. Explain the procedure to the patient; this should include what you are going to do and why and
how much time it will take.
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2. Protect patient clothing by putting the towel over the chest.
3. Remove false tooth or very loose tooth from the mouth
4. Place patient in the sitting position at the side of the bed or in the semi-fowlers position with
the head bend forward.
5. Lubricate and pass NG tube
6. Take a specimen of gastric juice before commencing lavage
7. Fill the tubing with sterile water or normal saline, and expel air.
8. Introduce about 300mls of lavage solution into the stomach
9. Invert funnel and allow abdominal content to siphon into the receiving bowl
10. Repeat until outflow fluid is clear.
11. Clamp and remove NG tube or leave in position and connect to a bag for continuous drainage
if indicated by doctor.
12. Give a mouth wash and make patient comfortable in bed.
13. Maintain strict intake and output chart
14. Monitor vital sign throughout the procedure and record.
15. Document the procedure and findings.
Precaution
Blood in aspirate fluid calls for immediate discontinuation of the procedure
Observe the patient for pallor, weakness and sign and symptoms of shock
Observe for signs and symptoms of unconsciousness
SPECIAL FEEDING PROBLEM OR FEEDING OR SPECIAL PATIENTS
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Injuries and operation in and around the mouth may pose problem for feeding. Under such
condition feeding is managed as follows:
Harelip Deformity
Infant with congenital harelip deformity may be able to take food without any problem. But if
complete cleft palate is present, the infant may need spoon feeding or feeding by NG tube, for
spoon feeding the infant is laid flat on the lap of the nurse or mother and fed by spoon to the
back of the mouth. Post –operatively, harelip feeding is done with a small narrow spoon which
will not stitches the mouth. Crying causes stretching of stitches or may cause removal, so crying
for feed should be avoided and the infant should be fed with sufficient amount of feed.
Cleft palate operation
Harelip is operated early but cleft palate is repaired at a later age but before the child starts
talking. After operation for cleft palate, feeding is done by NG tube or by a spouted feeding cup
with rubber or tube attached. Cold liquid feed is commonly given for few days. The semi-solid
foods and solid foods are given later. Water is given before and after each feed to clean the
mouth.
Operations over the mouth
Feeding problems arise after operations over tongue due to injury or tumour. Mostly the patient
is given only liquid feeds either by NG tube or by spouted feeding cup with rubber tube attached.
The tube should be put at the side mouth well to the back.
Portion. Slow and gentle irrigation of the mouth is usually done before and after feeding. All
cleaning and hygienically methods should b adopted for cleaning feeding cups, tubes and other
cooking items.
Fracture of the jaw
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Nasal feeding may be ordered or a spouted cup with rubber tubing may be used. The feed must
be introduce at the side of the mouth between the check and the teeth. Irrigation of the mouth is
carried out after each feeding.
Patient with tetanus and meningitis
Patients with Tetanus and meningitis have locked jaws, become stiff and fit frequently and so
cannot feed well. NG tube can be passed and the patient is tube fed with a fluid diet. NG tube
feeding may be ordered or a spouted cup with rubber tubing may be used. Sometimes a straw can
be used. The feed must be introduced at the side of the mouth between the check and the teeth.
Irrigation of the mouth is carried out after each feeding.
Patient with gastric condition
Patient with gastric condition are fed with small frequent and nonirritating food (regularly at
least 3-6 times a day a) to decrease gastric irrigation. Patient is encouraged to take food high in
vit. A.C. and iron to enhance tissue repair. If the patient is unable to eat well to meet nutritional
requirement, parenteral nutrition may be necessary. The nurse monitors the IV therapy and
nutritional status of the patient as well as intake and output. The patient is weighed on the daily
basis to ensure that the patient is maintaining or gaining weight.
The nurse instructs the patient to avoid certain drugs and food that have acid- producing potential
(alcohol, tobacoo, caffeinated beverages like tea, coffee, cocoa and diet rich in milk and cream,
spices, raw, leafy, uncooked vegetables and salads).
Diet in kidney conditions
Acute Glomerulo- nephritis; Protein restriction if urine output is low, sodium chloride is
restricted fats and carbohydrate is not restricted.
Nephritic syndrome: high protein diet, normal fat and carbohydrate intake restricted common salt
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Renal failure: protein is restricted, increase carbohydrate, normal intake of fats and salt is
restricted.
Diet in diabetes mellitus
1. Sweets are completely avoided
2. Carbohydrate diet are restricted and are eaten in moderation
3. Protein are eaten normally
4. Fats should be moderate since excess would result in weight gain
5. Vitamins and minerals are eaten adequately
The following foods are avoided (sweet and sweet drinks, carbonated drinks, cakes pastries,
creams, beer and wines and can fruits)
Diet in all heat conditions
1. Protein intake is in moderation especially in severe hypertensions
2. Carbohydrate is taken in moderations
3. Low salt intake
4. Saturated fats are restricted e.g. (beef, pork chicken, milk, cream, butter, egg yolk, coconut
and palm oil.
Diet in anaemia
The diet should contain more of iron, calcium, protein and vitamin C for synthesis of protein in
the blood. The diet for the patient with anemia should contain; liver, meat, eggs, spinach,
potatoes, wheat fruits etc.
COLOSTOMY AND ILEOSTOMY
Colostomy is the creation of artificial anus in which any part of the colon is brought to the
abdominal wall for the purpose of drainage of faecal matter while ileotomy is the creation of
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artificial anus in which any part of the ileum is brought onto the abdominal wall for the drainage
of faecal matter. There are two types temporary and permanent.
Indication: colostomy ulcerative colitis, rectal and anal strictures, large bowels obstructions and
cancer of any part of the colon before some operations, faeces in continence and congenital
absence of anus. Lleotomy; inflammatory bowel disease and penetrating trauma
1. Psychological preparations before the procedure.
2. Reassure the patient
3. Establish rapport by introducing yourself and asking about the patient name
4. Assess the patient knowledge about the disease condition and educate him
5. Explain the need, outcome and expectation of the surgery
6. Ensure that patient signs a consent form
7. Encourage patient to ask questions concerning her disease condition
8. Provide literature and models of a person who has undergone the procedure successfully to the
patient.
Colostomy Care
1. Observe the stoma for cyanosis and the gauze around for bleeding
2. Attach a colostomy bag with an adhesive and press to the skin.
3. Observe the site for bleeding, if bleeding persists reinforce the dressing and inform the
surgeon.
4. Remove the colostomy bag if it is 1/3 to ½ full and clean the skin around the stoma with a
warm tap water and a mild soap.
5. The stool is observed for colour, amount, odour consistency, and observe for the presence of
mucous and blood.
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6. Dry the skin sterile gauze and apply a skin barrier e.g. zinc oxide or Vaseline to the skin.
7. Ensure that the content does not come into contact with a the skin around the stoma
8. Asses the size of the stoma after 3wks for oedema has subsided
9. Observe for the presence of bowel movement
10. Put 4 tables of aspirin into the colostomy bag if not odour proof to deodorize the odour
11. Irrigation the colostomy with distilled water or normal saline to regularize the drainage and
to remove air from the colon.
Dietary Management
1. Monitor IV fluids until bowel sound returns; give sips of water then fluids diet and light diet
as patient’s tolerates it
2. Resume normal diet which is nutritious
3. Avoiding irritating foods such as spicy foods, hot pepper, acidic foods, alcohol, tough fiber
meat etc
4. Encourage patient to take low fiber diet
5. Masticate food well before swallowing
6. Supplements must be added to diet e.g. salt to compensate for the lost ones especially in
ileotomy
7. Excessive odour and gas forming foods like beans, onion, cabbage, eggs too much fish is
avoided A void excess fluids, oranges and green vegetable.
8. Carbonated beverages like soda and coke are avoided.
COMPLICATIONS: bleeding, infection, stenosis, retraction of colostomy, prolapsed of

colostomy and excoriation of the peristomal skin.
STOMA CARE BASICS
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Two basic types of diversions
 Urinary
 Faecal
URINARY DIVERSIONS
Reasons for diversions
 Removal of bladder from cancer
 Neurogenic bladder, congenital anomalies, strictures, trauma to the bladder, and
chronic infections with deterioration of renal function
TYPES OF DIVERSIONS
There are two types of diversion; these are incontinent and continent diversions.
A. INCONTINENT
 Ileal conduit
 Cutaneous ureterostomy
 Nephrostomy
ILEAL CONDUIT
This is the most common type.
Ureters are implanted into a segment of the ileum that has been resected. Ureters are
anastomosed into one end of the conduit and the other end is brought out through the abdominal
wall to form a stoma. There is no valve or voluntary control.
Advantages: Good urine flow with few physiologic alterations.
Disadvantages: Surgical procedure is complex. Must wear an external collecting device. Must
care for stoma and drainage bag.
ILEAL CONDUIT
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Figure 5-1 Diagram of illeal conduit
CUTANEOUS URETEROSTOMY
Ureters are excised from the bladder and brought through the abdominal wall to form stoma.
Advantages: Not considered major surgery
Disadvantages: External collecting device must be worn. Possibility of stricture or stenosis of
small stoma.
CUTANEOUS URETEROSTOMY
Figure 5-2 Diagram of cutaneous ureterostomy

NEPHROSTOMY
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Catheter is inserted into the pelvis of the kidney. May be done to one or both kidneys and may
be temporary or permanent. Most frequently done in advanced disease as a palliative measure.
Advantage: No need for major surgery
Disadvantage: High risk of renal infection. Predisposition to calculus formation from catheter.
May have to be changed every month. Catheter should not be clamped, should remain open.
Figure 5-3 Picture of a baby with nephrostomy

B. CONTINENT DIVERSIONS
KOCK POUCH
Loops of intestine are anastomosed together and then connected to the abdomen via the stomal
segment. Ureters are attached to the pouch above a valve, which prevents reflux of urine to the
kidney. A second valve is placed in the intestinal segment leading to the stoma.
KOCK POUCH
Figure 5-4 Diagram of Kock pouch
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INDIANA POUCH
Ureters are anastomosed to the colon portion of the reservoir in a manner to prevent reflux. The
ileocecal valve is used to provide continence and the section of ileum that extends from the
intestinal reservoir to the skin is made narrower to prevent urine leakage.
INDIANA POUCH
Figure 5-5 Diagram of Indian pouch
CONTINENT URINARY DIVERSIONS

The stoma is usually flush with the skin and placed lower on the abdomen than the ileal conduit
stoma. Patient will need to self-catheterize every 4-6 hours and will need to irrigate the internal
reservoir to remove mucus, but will not have to wear an external collection device.
COMPLICATIONS
 Breakdown of the anastomoses in the GI tract.
 Leakage from the ureteroileal or ureterosigmoid anastomosis
 Paralytic ileus
 Obstruction of ureters
 Wound infection
 Mucocutaneous separation
 Stomal necrosis
 Wound infection
 Mucocutaneous separation
 Stomal necrosis
NURSING MANAGEMENT
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PRE-OP CARE
 Assess ability and readiness to learn before initiating a teaching program
 Involve the patient’s family in the teaching process
 Teach the patient who will have a continent diversion how to catheterize and
irrigate and adhere to a strict schedule
 Patient will require complete bowel clean-out. Assist as needed with bowel prep
as ordered.
 Allow patient/family opportunity to explore feelings and begin to cope with
changes.
N. B:
Patients who have been well informed about the surgical procedure, post-operative period
and long-term management goals are better able to adjust to the entire experience than
those who have not.
POSTOPERATIVE CARE
Stents placed in ileal conduit for 7-10 days to promote urinary drainage. If continent
urostomy, will have catheter or stent in stoma (sutured in place) to allow drainage from
reservoir.
Drain tube in pelvic area for drainage of blood and surgical fluids.
May have NG tube until effective intestinal peristalsis returned. May then start on clear
liquids to advance as tolerated.
With ileal conduit, clear pouch placed over stoma so that it can be easily assessed.
Careful visualization of stoma in contact with catheter.
Monitor urine output carefully.
Blood in urine is expected in immediate postop period with gradual clearing.
Mucus is present in urine because it is secreted by the intestines as a result of the
irritating effect of the urine
High fluid intake is encouraged to flush the ileal conduit or continent diversion.
Be aware that patient is at greater risk for UTI.
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Stomal or loop stenosis may result in urine being retained in the conduit with subsequent
electrolyte imbalances.
Strive to keep urine acidic. Alkaline urine promotes encrustation and stone formation.
Ileal conduit stoma edema will begin to subside within 7 days after surgery and continue
to decrease in size gradually for the next 6 to 8 weeks.
Elderly and patients with limited manual dexterity may need special assistance.
Patients need to know where to purchase supplies, emergency telephone numbers,
ostomy support group contact information, follow-up appointments with nurse and
doctor.
Problems with the stoma may include bleeding, stenosis or prolapse.
BOWEL DIVERSIONS
A. INCONTINENT TYPES OF DIVERSIONS:
Colostomy-opening between the colon and the abdominal wall.
b. Ascending colostomy:
Semi-liquid stool consistency, increased fluid requirements, needs appliance and skin barriers,
cannot be irrigated.
Indications for surgery: perforating diverticulitis in lower colon, trauma, inoperable tumors of
colon, rectum or pelvis, rectovaginal fistula.
c. Transverse colostomy:
Semi-formed stool consistency, possibly increased fluid requirement, uncommon bowel
regulation, requires appliance and skin barrier, cannot irrigate.
Indications for surgery: Same as for ascending colostomy. May also be performed in children
who are born with imperforate anus
d. Sigmoid colostomy-
Formed stool consistency, no change in fluid requirements, bowel regulation possible with
irrigations and/or diet; need for appliances and barriers dependent on regulation.
Indications for surgery: cancer of the rectum or rectosigmoid area, perforating diverticulum,
trauma.
e. Ileostomy
Opening from the ileum or small intestine through the abdominal wall. Bypasses the entire large
intestine. Stool is liquid to semiliquid consistency and contains proteolytic enzymes, Increased
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fluid requirement. No bowel regulation or irrigation. Requires wearing an appliance and skin
barrier.
 Indications for surgery: ulcerative colitis, Crohn’s disease, trauma, cancer, birth defect,
familial polyposis.
 Surgical interventions
Loop stoma-Closure of colostomy is anticipated. Temporary large stoma where loop of bowel is
brought to abdominal surface and opening created in anterior wall of bowel to provide fecal
diversion. One stoma with a proximal (drains stool) and distal (drains mucus) opening and an
intact posterior wall that separates the two openings. The loop is sutured to the abdominal wall
and held in place with a plastic rod for 7-10 days.
LOOP STOMA
Figure 5-6 Picture of loop stoma

End stoma
One stoma formed from the proximal end of the bowel with the portion of the GI tract either
removed (permanent) or sewn closed (Hartmann’s pouch) and left in the abdominal cavity.
END STOMA WITH HARTMANN’S POUCH
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Figure 5-7 Diagram of end stoma with Hartmann’s pouch
Double-barrel stoma
Bowel is surgically severed and two ends are brought out onto the abdomen as two separate
stomas. The proximal end is the functional stoma. The distal end is nonfunctioning, called a
mucus fistula. Intended as a temporary diversion in cases where resection is required due to
perforation or necrosis.
DOUBLE-BARREL STOMA
Figure 5-8 Diagram of double barrel stoma

B. CONTINENT FAECAL DIVERSIONS
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Ileoanal pull-through-The colon is removed and ileum is anastomosed or connected to an intact
anal sphincter.
Ileoanal reservoir-Internal pouch created from ileum. End of pouch sewn or anastomosed to the
anus. Surgery is done in several stages and patient may have a temporary colostomy (6-12
weeks) until ileal pouch is healed.
ILEOANAL RESERVOIR
Figure 5-9 Diagram of

Special considerations for patients who have ileoanal reservoirs
Kegel exercises will help them to strengthen the pelvic floor and provide muscle control
for continence.
May have mucus discharge from rectum.
May have frequent stools. Must be meticulous with perianal skin care and use barrier
(zinc oxide) consistently.
Eliminate foods known to increase bowel activity and add foods that slow activity.
Increase fiber, decrease sugars.
May need Metamucil, antidiarrheals.
May have night incontinence and have to wear a pad to bed.
Should not respond to every urge to defecate to help increase pouch capacity.
Kock Pouch
Internal pouch created from a segment of the ileum. Part of the pouch is brought out low onto
the abdomen as the external stoma. A one-way nipple valve allows fecal contents to drain when
a catheter is intermittently inserted in the stoma. No external collecting device is required.
Immediately after surgery, a drainage catheter is left in place for 2-4 weeks. This catheter is
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irrigated with 20 ml of NS every 3-4 hours. Patients are taught to catheterize intermittently with
28fr. Catheter.
NURSING MANAGEMENT
PREOPERATIVE
Focus on patient teaching
Determine patient’s ability to perform self care, identify support systems
Identify potential problems that could be modified to facilitate learning
Nurse will be administering osmotic lavage (Go-Lytely) and giving IV and oral
antibiotics. Neomycin and erythromycin are given orally to decrease the number of
intracolonic bacteria.
Focus on assessing the stoma, protecting the skin, selecting the pouch and assisting
the patient to adapt psychologically to the body change.
Observe for the type of stoma, color, size, location of stoma, and peristomal skin.
More post op considerations:
Stomal characteristics
Mucosa is rose to brick red
Pale may indicate anaemia
Blanching, dark red or purple indicates inadequate blood supply to the stoma or bowel from
adhesions, low flow states, or excessive tension on the bowel at the time of construction.
Black indicates necrosis.
Stoma should be assessed and color documented every 8 hours.
GOOD STOMA BAD STOMA
Figure 5-10 Pictures of good and bad stomas
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What else should you expect to see when you examine the stoma?
- There should be mild to moderate edema in the first 5-7 days post-op. Severe edema may
indicate obstruction of the stoma, allergic reaction to food or gastroenteritis.
- Blood oozing from the stomal mucosa when touched is normal because it is so vascular.
- Tension at the stoma site where it is sutured to the skin can create poor healing or necrosis of
the stomal skin edge and retraction of the stoma into the abdomen. This is called
Mucocutaneous separation.
What about pouching?
Pouch is first applied in surgery, but the stoma does not function for 2-4 days post-op. At first
stomal drainage consists of mucus and serosanguinous fluid. As peristalsis returns, flatus and
fecal drainage returns, usually in 2-4 days.
What needs to observed and documented?
 Volume
 Color
 consistency
What about eating?
For the colostomy patient there are essentially no restrictions, but for the ileostomy patient it is
important for some foods to be avoided to prevent an intestinal blockage.
What to avoid
Stringy, high fiber foods like celery, coconut, corn, coleslaw, the membranes on citrus
fruits, peas, popcorn, spinach, dried fruits, nuts, pineapple, seeds, and fruit and vegetable
skins.
Other food issues patients need to know about
Fish, eggs, beer, and carbonated beverages can cause excessive foul odor.
Encourage your patients to eat at regular intervals, chew food well and drink adequate
fluids. Avoid overeating and excessive weight gain.
What about the pouch?
The opening should be about 1/8 inch larger than the stoma.
Teach your patient to empty the pouch when it is no more than 1/3 full and to cleanse the
pouch from the bottom with a squeeze bottle filled with water (one piece unit). The two
piece unit can be snapped off, washed and snapped back on.
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Change the entire unit (one or two piece) every 4-7 days depending on stability of seal.
Management options for permanent descending colostomy
Wearing a drainable pouch at all times
Colostomy irrigation to establish regularity and relieve constipation. Candidates for this
option are assessed for past bowel habits and frequency of stools, location of colostomy,
age, independence, dexterity, general health and personal preference.
ONE AND TWO PIECE UNITS
Figure 5-11 Pictures of one and two piece units

CHANGING OF COLOSTOMY BAG AND CARE OF STOMA
Certain disease conditions require surgical interventions to create and opening into the
abdominal wall for feacal or urinary elimination e. g. colon cancer or trauma. Colostomy is a
surgical procedure performed to create an opening into the colon through the abdominal wall for
faecal matter elimination. The piece of intestine that is brought out onto the patient’s abdominal
wall is stoma.
REQUIREMENTS
Basin with warm or tap water, skin barrier, ostomy deodorant, mild detergent, pouch closer
device i.e. a clamp or artery forceps and a stethoscope as well as ostomy belt. Two pairs of
gloves disposable and sterile, mackintosh and dressing towel, large receiver, measuring jug, new
stoma bag, gallipot with sterile gauze and stoma adhesive.
PROCEDURE
1. Explain procedure to the patient and ensure privacy

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2. Prepare and send trolley to bedside.
3. Turn down top sheet to expose stoma.
4. Protect site with mackintosh and dressing towel
5. put on disposable gloves and remove soiled bag gently and place in large receiver observe
stoma for colour, swelling trauma, peristomal skin and healing .stoma should be moist and
reddish pain, noting scars, folds, skin break down, observe effluent from stoma and record on the
intake and output chart. Remove disposable gloves wash and dry hands.
6. Put on sterile gloves, gently clean the peristomal skin with soap/mild detergent and warm tap
water by using sterile gauze.
7. Dry area gently with sterile cotton wool balls and apply barrier cream/zinc Oxide powder or
Vaseline
8. Estimate stoma or measure with measuring tape or guide and fit correct size of stoma bag.
9. Remove gloves, wash and day hands
10. Make patient comfortable and thank him (ask the patient whether he/she is comfortable)
11. Decontaminate and discards soiled articles.
Documents procedure and report any abnormalities, record the amount and appearance of stool
drainage bag size of stoma, colour and texture of stool, condition peristomal skin, sutures and the
skin barrier applied. Record patient’s level of participation and the need for teaching.
ILEOSTOMY CARE
Why is ileostomy care so different from colostomy care?
The drainage from the ileostomy contains proteolytic enzymes that literally digest the skin. That
is why skin care is so important for your ileostomy patient.
ILEOSTOMY CARE
The drainage is liquid in consistency, constant and extremely irritating to the skin. It is a dark
green color initially that progresses to yellowish brown when the patient begins to eat.
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Pay attention to fluid and electrolyte balance, especially potassium, sodium and fluid
deficits!!!!
Faecal output can range from 1000-1500ml every 24 hours. It should begin to decrease slightly
within 10-15 days to an average of about 800 ml per day.
Instruct your patient to drink at least 1-2 liters of fluid per day, more if they have diarrhea
and in the summer when they are perspiring.
Encourage them to drink fluids rich in electrolytes.
Begin on low roughage diet. Chew food completely, avoid stringy, fiber foods to prevent
blockage.
Ileal stoma also bleeds easily when touched.
Protection of the skin
Pouch with skin-protective barrier, adhesive backing, and pouch with opening cut no
more than 1/8 inch larger than the stoma.
Empty the pouch when it is 1/3 full and change it immediately if it has begun to leak.
Important to know
If the terminal ileum is removed, your patient may need Vitamin B12 injections every 3
months.
Enteric-coated, time-released meds or hard tablets may not be absorbed in the patient
who has had an ileostomy. Liquid or chewable meds are preferred.
Patients need vitamins A, D, E & K supplemented since colon absorption and synthesis
are eliminated.
What if my ileostomy patient develops a food blockage?
 Have them get into the knee-chest position and gently massage the area below the stoma.
 Try a warm tub bath to help relax abdominal muscles.
 Remove pouch and replace it with one that has a larger opening.
 May take fluids only as long as not vomiting and passing some stool. If vomiting or not
passing stool, take nothing by mouth and inform the surgeon.
PATIENT TEACHING
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The first step is looking at the stoma, progressing to assisting with emptying and
cleaning, and then to changing the pouch.
If the patient cannot progress to the point of willingness to learn, a caregiver must be
taught pouch change procedure and care until the patient is ready to learn
Pouch change is best performed before eating because the stoma is less active.
Ideally, the pouch should be changed every 5 to 7 days, but if it leaks it must be changed
immediately.
Managing odor
Pouches are made of odorproof plastic, but if the bag is not cleaned adequately when
emptied or if a leak has developed, there will be an odor.
There are products on the market to eliminate odor…drops that can be put in the bag at
changing or cleaning, odor neutralizing sprays when the pouch is changed, or bags with
built in charcoal filters.
There are also tablets that your patient can take by mouth that will eliminate the odor:
 Activated Charcoal
 Chlorophyllin Copper
 Bismuth Subgallate
When you teach ostomy care
Remind your patient how important it is to have them examine the peristomal skin for
any sign of breakdown. It is so much easier to prevent this rather than heal the skin!
Patients may bathe or shower with or without the pouch. Patients may swim with the
pouch in place as well.
Routine Skin Care
Proper method for pouch removal
Gently peel pouch away from the skin while pressing down on or supporting the skin
Avoid wiping the area with paper towels or toilet paper that leave a lot of lint behind.
Cleansing
– Routinely wash with warm water. Soap is likely to leave a residue that can cause
dermatitis and decrease the adhesiveness of the pouch. If soap is used be sure to
avoid ones with oils and rinse thoroughly.
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– Commercial cleansing wipes are convenient when away from home as long as they
do not contain lanolin or emollients.
Shaving
– Should be done routinely if peristomal skin is hairy to prevent folliculitis and pain
with pouch removal.
Remind your patients to not lift anything over 4.5 kg for the first 6 to 8 weeks after
surgery, otherwise they may resume normal activities.
Before your patient is discharged they should be able to
 Demonstrate cleaning and changing the pouch
 Verbalize where to obtain supplies
Adaptation to a stoma
It is a gradual process because the patient experiences grief over the loss of a body part and an
alteration in body image. Adjustment period is individualized. Patients are concerned about body
image, sexual activity, family responsibilities and changes in lifestyle.
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CHAPTER SIX
COLLECTION OF SPECIMEN
Definition
Specimens are samples of tissue, fluids, discharges and waste products from the body collected
for investigations and aid to diagnosis and a guide to treatment.
General Principles
1. Collect the requested specimen from the right patient.
2. Use correct container for each specimen
3. Use clean containers; for culture and sensitivity tests, use sterile containers.
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4. Avoid contamination of specimen during the procedure
5. Collect suitable quantities for the required investigations.
6. Close containers firmly
7. Clearly label the containers indicating the following:-
a. Patient’s name
b. The ward and bed number
c. Date and time of collection
d. Type of specimen and examination required
8. Wash hands
9. Ensure specimen is sent to the laboratory immediately together with the signed request form.
10. Wash hands again on return from the laboratory.
Collection 0f 24 – hours specimen of urine or timed urine collection
It is the collection of urine from a patient with in 24 hours into the Winchester bottle.
It is required to determine quantitative protein, creatinine, hormones and glucose excretion since
their levels in the urine change overtime. It is also done to detect presence of microbes such as
the mycobacterium in suspected cases of TB of the kidneys. The nurse should explain the
collection technique carefully to the patient.
Other nursing staff should also be aware that such an exercise is in progress.
REQUIREMENTS: suitable container – Winchester bottle, clean bedpan or urinal Graduated

jug, Funel
PROCEDURE
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1. Explain procedure and rational to patient a day or two before the examination and how patient
can assist
2. Label container with the following information:-
A.name of patient
b. ward
c. specimen
d. examination required
e. time and date of commencement and completion of collection of specimen
3. Choose a suitable time e.g.8am the following day.
4. Review instruction with patient in the morning of commencement of collection.
5. Put labeled container in a suitable place near patient’s bed
6. Ask patient to pass urine at the time collection begins and discard it.
7. Instruct patient to pass all subsequent urine into bedpan/urinal for the next 24 hours. This is
poured into the labeled container.
8. Ask patient to pass urine at time test ends, and add this to collected urine.
9. Remind patient that specimen collection period is completed
10. Record total amount of the urine collected on fluid chart and document in nurses’ notes.
11. Dispatch specimen to the appropriate laboratory with the request form
12. Wash hands
Documented in the patient chart, time urine collection started and completed the appearance,
odour, amount and time urine was sent to the laboratory.
COLLECTION OF MID-STREAM URINE SPECIMEN
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It is the collection of urine laboratory analysis. The patient begins to urinate and in the middle of
the voiding the nurse collects the specimen. The initial and the last steams are not collected
because they flush the urethral orifice and meatus of any resident bacteria
A common test performed on urine is a culture and sensitivity test in the laboratory, a few drops
of urine is placed on a special medium to determine whether or not bacterial is present. Readings
are made in 24- and 48 hours intervals and the final reading is made after 72 hours. If bacterial
are present, sensitivity testing is done to reveal which antibiotic will be effective against the
microorganisms. For the patients who are able to void voluntarily the nurse does the above
procedure for the patient.
INTRAVENOUS PYELOGRAPHY (IVP)
Purpose
This procedure is performed for detection of obstruction by stone, tumours, cysts, injury in
urinary tract, heamaturia, renal artery occasion and diagnosis of kidney diseases.
Procedure
Radi- opaque dye (Conray 420-2amp) is injected intravenously and then series of X-ray films are
taken to locate the filtering of dye by kidney and subsequently passing of the dye to ureters and
urinary bladder.
Nursing Implication
 Explain the procedure and purpose to the patient

 Ensure that a consent form is signed by the patient
 Bowel is cleaned by laxative orally (Dulcolax) 48 hrs before the procedure the procedure
or by enema in the morning of investigation or by both. To clear and liquid from the
colon.
 The patient is put on light diet or on strict fluid diet
 Keep the patient fasting for at least 6 hours
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 Remove any metallic object such as pins and buttons which may interfere during the
procedure.
 Tell the patient to put on gown.
 The nurse or one assistant escorts the patient to Radiology Dept.
 Reassure the patient before, during and after the procedure
 Inform patient that injection of dye causes flushing of face, discomfort nausea, vomiting
& headache.
 The nurse should be prepared to deal with such problems and handle them.
 After procedure, encourage the patient to take more fluid to get rid of the diet from the
body.
 Any untoward and signs symptoms should be reported to doctor.
 Encourage patient to have enough bed rest for at least 6 hours
 Observe the patient for signs of discomfort and delayed reaction to the dye such as
dyspnoea, tachycardia and rashes.
 Assess the vacular access site for bleeding or haematoma and ensure that pressure
dressing is applied to the site.
 Check vital signs every 30mins until the condition is stable and record
 Maintain input and output of the patient
 Document your findings
RETROGRADE PYELOGRAPHY
Purpose
This is performed after IVP or in place IVP. The observation in this procedure is better as the
dye is introduced directly into the urinary system
PROCEDURE
This procedure consists of introducing a radio-opaque dye by means of a catheter via external
urethral meatus to bladder and ureters up to pelvis of the kidney. The X-ray films are taken to
view the condition.
Nursing Implication
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 The procedure and purpose is explained to the patient
 A consent form is signed by the patient
 The procedure is usually carried out under local or general anaesthsia.
 The nurse informs the patient about the anaesthsia.
 Fasting is done for 6-8 hours before procedure
 If local anaesthsia is given a sedative or premedication is given beforehand.
 The patient is asked to remove dentures, ornaments and clothing
 He is encouraged to wear a gown
 The patient is usually placed in the lithotomic position.
 The feeling of introducing catheter and cystoscope should be explained to patient.
 After procedure, the patient should not stand or walk. He should take a rest.
 The nurse should monitor patients’ urine output and heamaturia.
 The patient should be encouraged to take more fluids
 Small amount of heamaturia is common with this procedure.
 Sometimes prophylactic antibiotics are given to prevent infection.
 Slight burning sensation during maturation for first one or two days is normal persistent
heamaturia or burning micturition should be reported to doctor.
 Document the procedure in the nurses’ note
CYSTOTOSCOPY
The procedure consists of direct viewing of urethra and bladder by insetting a hollow and lighted
telescopic tube called systoscope through the urethra to the bladder. The purpose of the
procedure is to diagnose, inspect and obtained biopsy and cytology test of ureter, bladder or
urethra.
Nursing Implication
 The procedure and purpose should be explained to the patient

 A consent form is signed by the patient
 Any metallic objects especially at the waist line are removed
 The procedure can be performed under local or general anaesthesia
 For the general aneasthsia, fasting is done for at least 8 hours
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 The prescribed pre-medication is administered and desired and side effect monitored
 The patient is placed in the lithotomic position.
 Privacy is provided and maintained throughout the procedure
 The bladder is emptied to avoid any puncture.
 After procedure, the patient is allowed to have enough bed rest
 The vital signs are checked and recorded 15mins for an hour, 30mins for 2 hours and
hourly until the condition is stable.
 Patient is served with analgesics if he complaints of pain.
 Monitor the urine output and record; observe the urine for any heamaturia. A small
amount of heamaturia is normal.
 The patient is encouraged to take more fluids to clear the urinary system.
 The prescribed antibiotics are given to prevent infection.
 Document all your findings.
Preparing a patient for peritoneal dialysis
Definition
Dialysis is the process that removes fluids and solutes wastes from the blood. There are two
types: haemodialysis and peritoneal dialysis. Peritoneal dialysis is a method of removing waste
products from the blood by passing a canular into the peritoneal cavity and infusing a dialysate
this hypertonic solution is left for the specified period of time and the drained. The semi-
permeable peritoneal membrane serves as filter to remove excess water, electrolytes and toxins
form the blood. Peritoneal dialysis has the three stages: infusing the dialysate into the cavity,
allowing the fluid to dwell in the cavity and draining the dialysate from the cavity. These are
sometimes called fill, dwell and drain times or stages.
Requirements
Dialysis administration set

Peritoneal dialysis solution as requested (usually 1.36 or 3.38 dextrose)
Drug e.g. heparin to prevent clots from occluding catheter, antibiotics
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Local anesthesia, skin suture set, a pair of sterile gloves, Antiseptic lotion swabs and dressing,
strapping, sterile syringe and needles for local anesthetic
PROCEDURE
1. Explain the procedure and the purpose to patient and reassure him
2. Ensure that the consent form has been signed.
3. Weight and check abdominal girth of patient and record before dialysis
4. Prepare skin of abdomen surgically
5. Let patient empty bladder and bowel
6. Check temperature, pulse, respiration and blood pressure and record
7. Warm dialysate to body temperature (37 oc- 38oc) to prevent intolerance, cramps and
hypothermia
8. Make patient comfortable in the supine position
9. Help doctor during the procedure
10. Remain with patient throughout the procedure.
Managing patients on peritoneal dialysis
Definition
This is the care given to patients having peritoneal dialysis which acts as a substitute for kidney
function during renal failure.
PROCEDURE
1. Use a septic technique throughout procedure to prevent peritonitis

2. Warm the dialysate to prevent intolerance, cramps and hypothermia
3. Allow the dialyzing solution to flow unrestricted into the peritoneal cavity (Usually about 10-
15 minutes).
4. Allow the fluid to remain in the peritoneal cavity for the prescribed time period (15-
30minutes).prepare the next exchange while the fluid is in the peritoneal cavity.
5. Unclamp the outflow tube and allow fluid to drain into the plastic bag attached to the
connecting tube (many take about 10-20 minutes).
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6. Check pulse and blood pressure every 15 minutes during the first exchange and every hour
thereafter
7. Check temperature 4 hourly and record
8. Observe for development of hypovolaemia and retention of dialysate (Outflow each time
should be approximately 100 to 300mls more than the inflow except for he first and possibly
the last couple of cycles)
9. If there is retention let patient move around or from side to side to bring the fluid to the
catheter tip.
10. Since the period of dialysis is lengthy, comfort measures such as turing of patient, back care
and massage of pressure areas, turning side to side, elevation of head of bed at frequent
intervals and allowing patient to sit in the chair for a brief period if the condition allows
promoted.
11. Check the dialysis set constantly for kinks or other obstructions
12. Report to physician if there is fluid accumulation of more than 300mls.
13. Monitor for fluid and electrolyte balance.
14. Change dressing over the insertion site at least daily using antiseptic lotion (preferably an
iodine solution) and a topical antibiotic ointment.
15. Observe the catheter insertion site for anathema, tenderness, drainage and swelling.
16. Keep dressing dry, arranging in such a way that the catheter does not touch skin directly.
17. Test urine during the procedure to check for glucosuria which may occur as a result of
absorption of glucose from the dialysate and electrolyte changes.
18. Relieve discomfort by:
a. Slowing down the rate of flow
b. Elevating head of bed
c. Massaging abdomen
d. Asking patient to move around
e. Administering prescribed analgesics
19. When the outflow drainage ceases run clamp off the drainage tube and infuse the next
exchange using strict aseptic technique.
20. Give high protein diet and liberal fluids during dialysis to place protein and fluid being lost
through dialysis (NB: about 10-20 grams of protein are lost with each dialysis process).
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21. Observe for signs of peritonitis which include
a. Cloudy peritoneal fluid out flow
b. Abdominal pain or tenderness, nausea, vomiting and anorexia
c. An increase in temperature
d. Discharge/inflammation around the catheter site.
The procedure is repeated until the blood chemistry levels improve. The usual time is 36-48
hours.
Document patient’s pre and post data e.g. weight, abdominal girth, vital signs. Dialysis balance,
the exact time of beginning and ending of each exchange, the medications added to the dialysate
infused, patient’s tolerance of the procedure, and the characteristic of the dialysate drained the
number of exchanges, and the nature of dressing of the catheter insertion site whether there is
drainage or bleeding.
Complications: peritonitis, bleeding, respiratory difficulty, abdominal pain, leakage of the fluid
and constipation.
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CHAPTER SEVEN
NURSING CARE OF PATIENTS WITH GYNECOLOGICAL CONDITIONS
The common gynecological conditions are; breast lump, vaginal discharges, blockage of
fallopian tubes, fibroid of the uterus and cancer of the cervix.
TAKING A HIGH VAGINAL SWAB/CERVICAL SWAB
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A high vaginal swab is taken from the vault of the vagina. A cervical swab is taken from the
cervix by using a sterile applicator; the procedure is done to take specimen for diagnostic
purpose.
Indications: Fungal infection of the vaginal and other sexually transmitted diseases
REQUIREMENTS
A try with the following: _

Sterile vaginal speculum in a sterile receiver and convered.
A lubricant e.g. K.Y. Jelly
Sterile swab in a test gallipot
Sterile swab in a sterile gallipot
Sterile water in a sterile gallipot
Sterile cotton wool swabs in a sterile bowl
Gloves
Waterproof sheet/mackintosh towel to protect bed.
Note: patient’s bladder should be empty before this procedure
PROCEDURE
2. Explain procedure and the rationale to patient.
3. Ensure privacy
4. Help patient into dorsal position with the knees flexed and vulva exposed.
5. Put mackintosh/ water proof sheet and towel under patient to protect bed and direct light
source onto the perineum.
6. Wash and dry hands and put on gloves.
7. Assess the condition of external genitalia, observe the urethra and the vaginal orifices for
redness, swelling, and discharge that is whitish, mucoid and purulent
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1. Swab the vulva with sterile water
2. Lubricate and insert speculum into the vagina to separate vaginal walls. Insert speculum
sideways. Turn speculum, open it and tighten the screw.(ask the patient to breath slowly to
relax her).
3. Remove swab from the tube and insert into vagina and rotate if for 360 degrees
4. Take swab as high possible in the vaginal vault.
5. Remove swab, observe for the presence of faeces and put it into its container.
6. Unscrew speculum to close it, turn it sideways and withdraw and place it in the receiver.
7. Clan vulva and leave patient dry.
8. Remove towel and mackintosh/water proof sheet
9. Remove gloves, make patient comfortable and thank he
10. Discard equipment, wash and dry hands
11. Label and ensure specimen is sent to the laboratory with the signed request form.
12. Record and report observation and finding; the type of culture obtained, date and time sent to
the lab, describe characteristics of the discharge and appearance of the vaginal orifice
SALPINGOGRAM / SALPINGOGRAPHY
It is the x-ray of the fallopian tubes after a radio-opaque dye has been introduced. It is used to
detect any blockage or narrowing of the tube in order to make the appropriate diagnosis.
Preparation for the procedure
1. Explain the procedure to the patient and the rationale

2. Inform the x-ray department
3. Get a written instruction for preparation for the x-ray technician on the specific
examination.
4. Give an aperients 36-48 hours before the procedure unless there is a diarrhea
5. Make sure patient signs a consent form
6. Remove any jewellery or metal articles on the patient
7. Cloth patient suitable preferably in a cotton attire
8. A nurse should accompany patient to the x-ray department and stay till the procedure is
completed
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9. Follow the instruction given by the radiologist
PAPANICOLAOU TEST
Pap test or smear is a cytological test performed for early detection of cervical cancer. It involves
scraping secretion from the cervix, spreading them on a slide, and immediately coating the slide
with a spray or solution to preserve specimen cell for nuclear staining. Cytologic evaluation then
outlines the cell maturity, morphology and metabolic activity.
The patient should be educated about the following before the procedure
 The use of vaginal douche 48 hrs as it washes away cellular deposits and prevents
adequate sampling.
 Instillation of vaginal medication 48hrs before the procedure makes cytological
interpretation difficult.
 Collection of specimen during menstruation prevents adequate sampling as menstrual
flow washes away cells (5 to 6 days before menses/1wk after menses)
Equipments vaginal speculum, sterile gloves, swab stick, three slides, solution, adjustable lamp,
drape and the lab request form, receiver for used instrument, receiver for used swab, draw
mackintosh and sheet, cotton wool balls in a gallipot and sponge holding forceps
PROCEDURE
1. Explain the procedure and the purpose to the patient and wash your hands
2. Encourage the patient to avoid and provide privacy
3. Inform patient to undress below the waist and lie on the examination table, drape her
genital area.
4. Label the glass with the patient name and the alphabets E”, C” and V” to differentiate
endocevical, cervical and vaginal specimens.
5. Place the patient in the lithotomic position with the buttock extended slightly beyond the
edge of the table and adjust the lamp to illuminate the genital area and fold back the
drape to expose the perineum wash hands, wear gloves and moisten the speculum with
warm water
6. Separate the labia with the thumb and forefinger by using the non sterile hand
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7. Inform the patient to take several breaths and insert the speculum into the vaginal
8. Insert a cotton tipped applicator into the cervical os and rotate it 360 degrees and remove
the applicator and apply it on the E” slide, over the cerval os-C” and posterior fornix-V”
and spray it with the solution to prevent drying of the cell.
9. Gently remove the speculum, remove gloves and wash your hands
10. Make the patient comfortable and send the specimen to the lab with appropriate request
form
11. Decontaminate the instruments and reassure the patient
Documentation: record the date and time of the specimen collection, any complications such as
slight bleeding, speculum pinching vaginal tissue and causing severe cramping as well as the
nursing actions taken.
Breast examination
Conditions of the breast are; cracked nipples, inflammations of the breast, breast abscess,
engorged breast and tumor of the breast.
Physical assessment of the breast and maxillae is part of periodic health maintenance
examination for both male and females of all ages. Breast cancer cannot be prevented but early
detection offers more treatment options and a greater chance of cure. A breast examination
performed by the nurse is accompanied by breast examination education.
This includes teaching the patient to perform monthly breast examination, discussing risk factors
and prompting the patient to seek recommended mammograms are essential for early diagnosis
and treatment of breast cancer.
Before the procedure, find out from the patient whether there is a family history of breast and
cervical cancer, she is using any hormonal medications, if the patient is post.
Menopausal and assess the age for a male with an enlarged breast. Instruct patient not to use
creams, lotions, powders and not to use shave the armpit 48 hours before the procedure, also
remind patient to inform you when there is any discomfort during the procedure.
1. Wash, dry and warm hands
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2. Explain the procedure to patient and provide privacy
3. Expose patient up to the waist
4. Observe both breast for change in contour and symmetry
5. Ask patient to place her left hand on her head
6. Use the pad or palmer surfaces of fingers starting from the periphery to the nipple in a
rotating motion or wedge sections to compress the breast tissue gently against the chest
wall
7. Proceed systematically to examine the entire breast including the tail and areola, observe
for warm temperature, tenderness, pain erythematic and nodules, dimpling of the breast,
swelling and thickening of breast skin
8. Palpate every part of the breast including the nipples and observe for abnormalities such
as inflammations, discharges, nodules or lesions
9. Resume patient during the procedure
10. Squeeze the nipple gently between the thumb and index fingers, note whether any
discharged is expressed.
11. Ask patient to put the hand down and feel or the lymph nodes in the clavicle and the
axilla, nodes should be less than 1cm and not tender
12. Give appropriate answers to questions asked by the patient
13. Repeat the procedure on the right breast
14. Thank patient and remove screen
16. Document the date and time, finding of the abnormalities and absence of abnormalities,
patient response to findings, teaching and follow up plan.
Nursing measures to induce urination
1. Sometimes the presence of visitors or proper lack of privacy causes retention of urine.
Reassure the patient and provide privacy so that the patient may pass urine
2. Serve him or her with a urinal or bedpan
3. Maintenance of proper or convenient position also relaxes bladder sphincter to cause
urinations. Help the patient either to sit or stand to enable normal position of urination.
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4. Sometimes the sound of urination may induce urination, and so put on the neighboring
tap for the patient to hear flow or running of water and psychological reasons this will
induce him to pass urine
5. Apply warmth to the lower abdomen
6. Give plenty water or fluid orally
7. Pour cold or warm water alternatively over the public area this may induce the passage of
urine
8. Cary out aseptic catheterization if the above measures fail
Catheterization
It is the introduction of a catheter in to a hollow or an organ having a fluid in it. Whiles urethral
catheterization is the passage of urethral catheter into the urinary bladder for the purpose of
emptying the bladder.
Types of catheterization
a. Cardiac catheterization
b .Arterial catheterization
c. Ureteric catheterization
d. Supra- pubic catheterization
e. Urethral catheterization.
Urethral catheters commonly used
The straight catheter or Negation’s or Jacque’s catheter:- this is the most common form of
catheter. It is straight and usually has one eye but sometimes there are two eyes and the end of
the catheter is solid.
Pasteau’s catheter or Thiemann’s catheter:- This may of a rubber or plastic and has a molded
curve at the tip which is both solid and tapered. The shape and the stuffiness make it easier to
introduce through a male urethra which is obstructed by prostatic.
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Enlargement. It happens to be the most useful catheter for general purpose.
Whistle- tip catheter: - This is also a straight rubber or plastic catheter in which the tip is
beveled and open, in addition to this, is a side eye. This type is used mainly for postoperative
drainage of the bladder following prostatectomy. If the open tip is not beveled the catheter is
sometimes described as’Flarris’ catheter.
Folyey’s catheter: - This is a straight rubber or polythene catheter with a thin rubber cuff or
balloon near the tip behind the eye. This balloon after introduce of the catheter into the bladder is
distended with sterile water injected through a thin tube incorporated in the wall of the catheter.
When 5-10mls of sterile water is injected the balloon it distends it and the catheter is retained in
the bladder. Some of the catheters have a large balloon with a capacity of 50-150mls and when
used the catheter forms a plug in the cavity left after removal of the prostate. Its presence limits
bleeding by pressure and prevents the accumulation of clots.
Malecot catheter: _ This has a conical bulb with and a solid tip with two or four little tuber
wings which prevents it being pulled out accidentally.
Inserting catheter for a female patient
Indwelling catheterization involves passing a plastic tube into the bladder through the urethra to
drain urine form the bladder or to obtained sterile urine specimen.
Intermittent catheterization may be used to obtain a sample or to relieve bladder distention.

Indwelling catheters may be passed to keep bladder empty and prevent urinary retention while
the long term indwelling catheters are used to control incontinence prevent retention or prevent
the leakage of urine.
Other indications are: surgery, to prevent bed sores urethral stricture or trauma, labour,
specimen collection, fistula, operation over the bladder or prostate urethra and paralysis of the
bladder
Catheterization is a sterile procedure
PROCEDURE
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1. Wash, dry hands and assembly the following
Sterile indwelling catheter (correct size 14-16,7-9)
Syringe filled with 10-20mls of normal saline or sterile water jug of warm, soap and towel,
sterile gloves, intake and output chart sterile drape sterile fenestrated drape, sterile cotton wool
Antiseptic cleaning agent (cetrimide or Hibitane in a gallipot), urine bag, Lubricant e.g.
xylocaine jelly
Urine specimen container and laboratory request form where applicable sterile, forceps, receiver
for soiled swabs and bedpan
2. Explain procedure to patient, provide privacy and ensure adequate lighting
3. Protect bed with mackintosh and towel
4. Wash and dry hand and put on a sterile glove
5. Instruct assistant to place patient in the supine position with knees flexed and legs separated
6. Insert bedpan under patient and wash perineum thoroughly with soap and water
7. Remove bedpan and drape with a sterile towel
8. Remove the gloves, wear another sterile, glove and clean the vulva with an antiseptic lotion
9. Lubricate catheter with xylocaine jelly
10. Use the non dominant hand to part the labia and establish a firm but gently position.
11. Pick a cotton wool ball soaked in a antiseptic with forceps in the dominant hand and swab
one side of the labia majora from top to bottom, use a new ball for opposite side.
12. Repeat procedure for the labia minora, use cotton ball wool to clean over the meatus.
13. Insert catheter into the urethra gently about 5cm
14Inflate the balloon of the catheter with the sterile water according to manufacture’s direction
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15. Collection a urine specimen if needed and allow 20-30mls to flow into bottle without bottle
touching the catheter.
16. Tape catheter to the abdomen or the thigh snugly so that it will not pull on the bladder and
cause trauma of the urethra and the neck of the bladder.
17. Connect catheter to urine bag, hang to bed and secure in position to prevent back flow of
urine into the urinary bladder.
18. Observe colour note amount of urine, colour, and odour
19. Remove drape and make patient comfortable in bed and discard trolley
20. Thank patient and discard trolley
21. Wash hands and document the abnormalities; time and date the catheter was passed, note the
size, type of catheter, amount of sterile water used to inflate the balloons, patient’s responses to
the procedures and the amount , colour odour and quality of the urine passed.
Complication: bladder infections, trauma to the urethra and severe pain
CATHETER HYGIENE
This is a special care to the urinary meatus and catheter to reduce the likelihood of infection.
Patient with indwelling catheter requires specific perinea hygiene to reduce the risk of
UTI.Indwelling catheter may provide a route for infection to enter the body, the use of powders
and lotions are not advisable because of risk of growth of microorganism which may travel to the
urinary tract. It is important to remember that patients are embarrassed or frightened by the
catheter and related care, so, emotional needs should be addressed.
Important points t know about indwelling catheter
Perform catheter care at least twice a day
Check drainage tubing at frequent intervals to assess for kinks or clogs.
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Always keep the drainage bag below the level of the bladder without kinks to ensure gravity
drainage.
Fasten catheter to the patient’s thigh to prevent tension on the urinary bladder.
Empty the drainage bag at least every 8 hours and record the amount, odour, colour and
consistency
Change drainage bag and catheter according to hospital policy
REQUIREMENTS
Sterile tray containing sterile wool or gauze swabs sterile towel
Sterile water/saline or hibitance 1 – 500, disposable bag for dirty dressing, pair of sterile gloves,
mackintosh and towel receiver for used towel.
PROCEDURE
1. Inform patient and ensure privacy
2. Assemble necessary items. And raise bed to appropriate working height and if side rails are
raised lower it at the working side.
3. Place mackintosh and towel under patients’s buttocks
4. Turn back bed cloth
5. Wash hands and put on sterile gloves
6. Place sterile towel beneath catheter
7. Assess the urethral meatus and surrounding tissues for inflammations, swelling, and discharge
and ask patient if burning sensation or discomfort is felt
8. Swab the urethral orifice in a circular motion from the most inner surface to the outside along
the length of catheter about 10cm
9. Swab the exterior of the catheter carefully at its insertion
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10. Dry area with dry swabs
11. Remember to repeat the care any time it become solied with stool or other drainage.
12. Remove and discard gloves
14. Decontaminate and discard all items immediately
15. Document the time and date procedure was performed, the condition of the area around the
catheter insertion and the character of the urine.
NOTES:
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CHAPTER EIGHT
TAKING A PENILE SWAB
This is taking swab from the male urethral orifice specimen to be sent to the lab for culture and
sensitivity test. It done whenever there is a suspected urethra discharge.
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REQUIREMENTS
A tray with:-
Sterile swab in a test tube
Sterile swabs in a bowl
Receiver
Savlon 1-200 in a gallipot
Towel
PROCEDURE
1. Explain procedure and rationale to patient
2. Ensure privacy
3. Wash and dry hands and send tray to bed side
4. Put patient in a comfortable position
5. Ask patient tactfully to expose his genital area
6. Cover with a towel
8. Retract prepuce to obtain maximum visibility of area for the swab
9. Remove swab from tube
10. Rotate swab gently in the urethral meatus about 360 degrees to absorb the discharges
11. Retrieve swab and put back in to test – tube
12. Swab prepuce with savlon 1- 200 and dry with sterile cotton wool
13. Remove gloves and make patient comfortable
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14. Remove screen, discard and clean equipment and wash and dry hands
15. Label and ensure specimen is sent to the laboratory with the signed request form
16. Record and report observations.
CATHETERIZATION OF A MALE PATIENT
REQUIREMENTS
As for female catheterization with the required size of catheter (20-22)
PROCEDURE
1. As for female catheterization
2. Put patient in the supine position
3. Lay mackintosh and clean dressing towel later with a sterile dressing towel
4. Lubricate catheter well for 18cm with the sterile water or solution jelly to minimize infection
and to ease insertion.
5. Clean and dry the glans penis or area around the penis using the left hand and clean if patient
is uncircumcised. Place a sterile swab around the penis.
6. Where necessary retract the prepuce between the thumb and figure so that the urethral meatus
is exposed.
7. Clean the area with antiseptic lotion wiping with circular motion from the urethral meatus
down to the base of the glans and repeat cleaning three more times using clean cotton ball
each time until the area is clean.
8. To straighten the urethra, lift the pains to an angle of about 600-90
9. Insert the catheter gently for about 16cm or until urine begins to flow.
NB: sight resistance will often be met as the catheter encounters the external sphincter, therefore
pause briefly and
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10. Ask the patient to breath in deeply resulting in sufficient relaxation for the catheter to be
passed readily for the urine to flow.
11. Inflate the balloon with the require amount of fluid.
12. Replace retracted prepuce over the glans after catherization to prevent oedema
13. Remove and discard gloves.
14. Clean all equipment thoroughly immediately after use if not disposable and sterilize and
store.
15. Wash hands and documents and abnormalities; time and date the catheter was passed, not the
size, type of catheter, amount of sterile water used to inflate the balloon, patient’s responses
to the procedures and the amount, colour, odour and quality of the urine passed.
Note:
1. There must be sufficient slack on the tubing to allow the patient to move freely.
2. The tubing must not be occluded by shape bends or pressure from the bed clothes or the
patient.
BLADDER TRAINING
3. Plan a drinking schedule for patient
a. to attempt to empty the bladder shortly after awaking
b.fluid should be limited to the late evening thus limiting the risk of being incontinent during the
night.
4. Make patient comfortable in the sitting up position, bending forward slowly thus creating
pressure on the bladder.
5. Ask patient to apply slight pressure with a towel over the bladder
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6.establish regular schedule pattern (e.g. if the patient knows that a frequent “wetting time” is
10.30am, then provision for patient to attempt to void should be at 10.00am. time attempting to
empty the bladder by the patient should be the same each day)
7. Stimulus or clues explain to patient to understand and become sensitive to stimuli or clues of a
need to empty the bladder e.g.chilness, sensation in the abdomen, sweating etc.
8. Apply other measures which are use to help patient void e.g. drinking fluids, or listening to a
running water or tape.
9. If patient is able to use any of the above methods to stimulate and empty the bladder, the
training programme is successful.
10. Congratulate patient for his effort and co- operations
BLADDER IRRIGATION
1. Bladder irrigation or lavage is a method of washing out the bladder with antiseptic fluid or
normal saline. To provide a means of constant bladder irrigation while maintaining a closed
drainage urinary system. This procedure is carried out to instill medication into the bladder, or to
remove blood clot or urinary sedmiments which may block the catheter. There are two types of
bladder irrigation open and closed- system irrigation in the open system, the closed bladder
drainages is opened and the catheter s disconnected from the drainage bag before the bladder
irrigation is carried out. In the closed- system a three- way catheter is passed which has 3 ports:
firs one for inflation of the retention balloon, second for urine drainage and the last one for
infusing irrigant this is indicated in surgical procedures such as prostate resection, bladder
surgery and trauma.
REQUIREMENTS
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In addition of the requirement for indwelling catheter the following are needed sterile tray, sterile
jug for lotion, sterile receiver containing funnel, tubing, normal saline glass connection, clip
receiver for used apparatus and receiver for used fluid
PROCEDURE
2. After the catheter has been passed, connect tubing, funnel and glass connection.
3. Expel air from the apparatus before connecting to the urethral catheter
4. Disconnect drainage bag from catheter, wrap end with sterile gauze and place it in a sterile
receiver.
5. Connect irrigation apparatus to urethral catheter
6. Hold the funnel above the level of the catheter to allow slow flow of fluid into the bladder
using 300mls of fluid and siphon back, repeat the process until the return fluid is clear.
7. Observe patient for any abnormalities and report
8. Check whether all the fluids is siphoned back
9. Disconnect apparatus from the urethral catheter and reconnect to the drainage bag.
10. Remove, discard gloves, wash and dry hands.
11.Make patient comfortable in bed
12. Decontaminate and sterilized used equipment if not disposable, wash and dry hands.
13. Document procedure; amount of irrigation infused and amount of drainage measured,
describe patient’s tolerance of the procedure such as pain and bladder spasm, not the colour,
clarity, volume, and debris in the drainage.
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CHAPTER NINE
NURSING MANAGEMENT OF PATIENTS WITH ORTHOPEDIC DISORDERS
Appliances for immobility are splint, traction, braces and plaster of Paris (pop) purpose for the
application of the above appliances
 For immobilization and fixation
 Correction of deformity
 Prevention of deformity
 Relief of pain prevention of complication
 Restore function by gradual encouraged of movements
GENERAL PRE- OPERATIVE PREPARATION FOR ORTHOPAEDIC OPERATIONS
Orthopedic surgery embraces all conditions affecting the musculoskeletal system where either
open or closed reduction, fixation, immobilization or correction of various deformities and
injuries are carried out.
In addition to gereral pre- operation management
1. Prepare patient physically, socially, and mentally to overcome natural anxiety
2. Orientate patient and relatives to the limb fitting centre (e.g.in case of the need for a
prostheisis)
3. Discuss after care of prostheisis and other internal fixations ( in case of death)
4. Educate patient on breathing joint and muscle exercises
5. Educate patient on how to use bed urinal and other bed accessories such s trapeze before
operation.
6. Prepare skin area of operation including the area above and below the joint on the affected
side. (Shave patient where necessary, this is done on the day of operation to minimize infection)
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7. Follow general preoperative management till patient is taken to theatre
General post-operative nursing management for orthopedic operations
PROCEDURE
In addition to general postoperative nursing care:-
1. Immobilize patient as soon as he is put into bed to prevent complication
2. Encourage passive and active exercise early to prevent complication e.g. deep vein
thrombosis, pneumonia stiff joints and loss of muscle power
3. Support affected area with bed accessories needed e.g. Thomas splint, sandbag, lifting pulleys
water bags and trapeze.
4. Treat pressure area regularly and use air, heel or elbow ring to prevent pressure sores
5. Encourage patient to get patient out of bed soon as possible to prevent any complication
6. Encourage patient to take diet rich vitamins, protein and calcium.
7. Educate relatives on patient’s condition and ask them to give financial and social support for
long absence from work.
8. Involve social worker and public or community health nurse
9. Invite physiotherapist and a teacher where needed
10. Involve patient whilst assisting him in his general care (e.g. personal hygiene proper
movement in and out of bed to other places, use of Zimmer frame, crutches etc).
11. Rehabilitate patient to fit into the community.
Nursing management for patients with orthopedic prosthesis
Prosthesis is an artificial replacement for missing part of the body.
1. Invite the prosthetics or an orthris (specialist in orthopedic appliances) early as possible to

develop an attitude of hopefulness
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2. Ensure prosthesis is fitted as soon as it is ready (taking into consideration condition of the
stump).
3. Encourage patient to feel free to talk about prosthesis (if he wishes)
4. Instruct patient on how to use the prosthesis
5. Educate patient on how to care for the prosthesis.
6. Train patient to make satisfactory adjustment to his prosthesis
7. Listen to patient’s complaints and attend to his needs (e.g. pain, phantom limb etc).
8. Advice patient to report to the prosthetics periodically in case of any abnormality detected
TRACTION
Traction is commonly applied to a limb by means of a weight and pulley. It is usually applied on
the spine, pelvis, or long bones of the arm or legs.
Types of traction
Skin traction and skeletal traction
Skin traction
Skin traction is directly applied to the skin indirectly to the bone, it is ordered when a light
temporary or non- continuous pulling force is required, the force may be applied using adhesive
or non-adhesive traction tape or other skin traction devices such s the boot and belt. Adhesive
attachment allows more continuous traction whereas non-adhesive attachment allows easier
removal for daily skin care.
Contraindication for skin traction includes a severe injury with an open wound, an allergy to
tape or other skin traction equipment, dermatitis and varicose veins
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CARE OF PATIENT IN SKIN TRACTION
PROCEDURE
1. Explain procedure to patient and ensure privacy
2. Check vital sign record; assess patient’s neurovascular status of affected extremity (peripheral
pulses, colour, and amount of movement, oedema, numbness, temperature and sensation)
3. Assess patient regularly for sign of thrombi and emboli i.e. pulse, blood pressure respiration,
breath sounds for evidence of emboli, inspect extremity involved for redness swelling and pain
and patient’s mental status
4. Assess pressure area for signs of irrigation or breakdown in the continuity of the skin
especially bony prominence (knee, ankle, sacrum, elbow, chin and shoulders).areas susceptible
to pressure from the traction e.g. (the tibia for Buck’s extension)
5. Assess skin for allergies and sign for infection or injury, rashes and blister formation
6. Inspect traction apparatus regularly for level of elevation of foot end knee flexion on bed 20 to
30 degrees.
7. Ensure free play of rope on the pulley i.e. free swinging of the rope.
8. Ensure that weight is hanging freely and not resting on the bed or floor when bed is in the
lowest position
9. Ensure that the ropes are straight without knot or kink between point of attachment and in the
same plane as the long axis of the bone.
10. Ensure rope are securely attached with slip knot and the short end of rope are attached with a
tape
11. Ensure bed clothes and other objects do not impinge on the traction and spreader bar wide
enough to prevent the traction tape from rubbing on the bony prominence
12. Ensure patient is in the supine position and maintain body alignment when turning him.
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13. Ensure trapeze is padded to assist patient n lifting his body for back are and provide slipper
bedpan to minimize movement in bed.
14. Provide protective devices and measures to safeguard the skin example, water bags for the
heels, sacrum, shoulders and other pressure areas.
15. Treat pressure areas 4 hourly
16. Change adhesive skin traction as ordered, provide skin care and re- wrap into position.
17. Encourage patient to do deep- breathing, coughing and range of motion flexion and extension
exercise.
18. remove, gloves wash, dry document findings; patient’s care including checks of
neurovascular integrity, skin condition, respiratory status, elimination patterns, the patient
tolerance and the amount of traction weight used daily.
SKELETAL TRACTION
This procedure immobilizes a body part for prolonged periods by attaching weighted equipments
directly to the patient bones. In skeletal traction, an orthopedist inserts a pin, wire or plate
through the bone and attaches the traction equipment to the pins, screws or wire to exert a direct,
constant and longitudinal pulling force.
Indication for skeletal traction include: fractures of the tibia, femur and humerus.
Infection such as osteomyelitis contraindicates skeletal tractions requirements; same as wound

dressing
CARE OF A PATIENT IN SKELETAL TRACTION
PROCEDURE
1. Explain procedure to patient and ensure privacy
2. Set trolley with sterile dressing set sterile cotton wool balls; sterile gauze packs normal’s
saline and iodine.
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3. Wash hands, observe infection prevention measures and inspect the traction apparatus,
4. Ensure the patient is in appropriate position, and check that the head, knee and foot of bed are
properly elevated and trapeze should be well padded, and patient should be encouraged to use it
to move in bed and using the bed pan support foot in position with the prescribed orthopedic
devices such as sand or water bags to avoid foot drop like plantu flexion, inversion and eversion
5. Assess specific pressure areas for redness skin break down and provide back care and keep
bed dry from wrinkles and crumbs.
6. Turn patient as a unit to prevent any complications.
7. In case of dislodgement of Steinmann’s pin, support the parts; remove the weight, place
sandbag or water bags on either of the leg to maintain proper alignment
8. Asses neuro-vascular status of the affected extremities such as colour, edema, numbness and
tingling sensation. Encourage patient to report any changes in sensation or movement
immediately and serve the prescribed anti-coagulant.
9. Carefully inspect the pin site daily detect infections early and provide pin site care using
aseptic techniques.
10. Remove crusts from wound sites and sole of the feet, apply the prescribed dressing agent
with gauze loosely around the pin site, obtain sample if it is discharging for laboratory
investigation. Keep area clean and observe for inflammation and tenderness.
11. Teach patient deep breathing and coughing exercise, flexion extension of affected limb’ toes,
and range of motion exercises of the unaffected limb with the help of the trapeze The above will
prevent deep vein thrombosis and hypostatic pneumonia.
12. Maintenance of personal hygiene is achieved by giving the patient a bed bath and oral care.
13. Maintenance of nutritional status is achieved by feeding the patient with a lot of fluid,
roughage, fruits and nutritious food which is high in protein and vitamin D&C to promote early
fracture healing and prevent constipation.
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14. Thank patient for his cooperation, wash and dry hands. Document; patient’s care including
checks of neurovascular integrity, skin condition, respiratory status, elimination patterns, the
tolerance , the amount of traction weight used daily , note the condition of the pin site any care
given.
Complications: pressure ulcers, constipation, urinary calculi, hypostatic pneumonia,

thrombophlebitis and osteomyelitis at the pin site for skeletal traction.
POST-OPERATIVE MANAGEMENT FOR A PATIENT AFTER MANIPULATION

AND PLASTER OF PARIS (P. O. P.) CAST
POP is a hard mold that encases a body part, usually an extremity to provide immobilization
without a discomfort. It can be used treat fractures, dislocations, to correct deformities, promote
healing after general and plastic surgery, amputation, nerve and vascular repair. Casts may be
prepared from plaster, fiberglass or synthetic material, the one from plaster is inexpensive,
nontoxic, nonflammable, easy to mold and rarely causes allergic reaction or skin irrigation.
PROCEDURE
1. Receive patient into a rapture bed with minimal handing (handle wet cast with palms) to
prevent dent and pressure on bony prominences.
2. Ensure adequate ventilation of the cast by opening widows and putting on fans.
3. Elevate the affected part to prevent complications e.g. swelling.
4. Observe and report any excessive bleeding.
5. Put on bed cradle where necessary to help P. O. P. to dry quickly
6. Inspect fingers and toes for capillary flush or Banching test
7. Instruct patient to exercise the exposed fingers or toes at least every hour to improve
circulation.
8. Observe patient frequently and report immediately and warming signs e.g. numbness,
tingling or burning sensation, cyanosis, tightness or (odour indicating pus formation).
9. Split P. O. P immediately if necessary.
10. Observe cast edged for sores’ redness and irrigations
11. Inspect plaster daily for cracks, looseness standing (with urine or faeces) etc. and repair
where necessary.
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12. Serve small quantity of meals for the first few days to patient in hip spica until
adjustment is made to prevent diarrhea or constipation in the early stages.
13. Turn patient at least twice daily to prevent pulling of high calcium from bone into urine
and check fluid and electrolyte balance frequently to prevent renal calculi formation.
14. Act promptly to very complaint of pain or discomfort etc. made by patient.
15. Advice patient not to wet, cut, hit or interfere with P.O.P.in any way. Do not give small
toys to children (these can be pushed into the cast causing pressure sores and cracks).
16. Encourage patient in hip spica to use bed pan as they find it difficult to use, otherwise
protect anal area with water proof material and change when necessary.
17. Encourage relative and friends to visit and converse with patient to relieve boredom and
loss of morale.
18. Instruct patient not to put weight on a lower limb when he starts waling unless it is a
waling plaster with a heel.
19. Continue with general post operative care for orthopedic operation till patient is
discharged.
20. Patient must be encouraged to eat well balanced food; high protein, calcium, Vit C, D and
iron food also food high in fiber as well as fruits.
21. Follow discharge procedures.
NOTE:
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CHAPTER TEN
PREPARATION AND ASSISTING IN LAMINAR PUNCTURE
Lumbar puncture, also called a spinal puncture or spinal tap, is an invasive procedure performed
by a physician. It involves the introduction of a spinal needle into the subarachnoid space of the
spinal column at the lower back between the 3 rd and 4th lumbar vertebrae to drain the
cerebrospinal fluid. Lumbar puncture is done to measure cerebrospinal fluid pressure, to inject
anesthetic, diagnostic or therapeutic agents and to drain cerebrospinal fluid from the
subarachnoid space in case of intracranial hypertension.
Indications: spinal cord tumous, central nervous system infections and hemorrhage.
Equipments: antiseptic lotion, sterile swabs and gauze in a gallipot, anesthetic agent, 5ml syringe
and needles, sterile gloves, 4 test tubes, draw mackintosh and sheet, 2 receivers for used swab
and needles, plaster and scissors, annular.
PROCEDURE
1. Explain the procedure to the patient and reassure him to gain her cooperation.
2. Assess the patient ability to assume the require position for the procedure (fetal position or left
lateral with chin and knees bent to touch the chest).
3. Ensure consent form has been signed.
4. Ensure patient empties the bladder and bowel before the procedure begins.
5. Check vital signs and neurological status of the lower extremities: movement sensations, and
muscle strengths.
6. Provide privacy.
7. Wash hands, dry and put on gloves.
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8. Open the equipment tray taking care not to contaminate.
9. Provide adequate lighting at the puncture site.
10. Assist patient into a required position I e. lying or sitting and support him.
11. Stand in front of patient to support and prevent him from falling during the procedure.
12. Continue to support, observe and reassure patient throughout the procedure.
13. Apply firm strapping or pressure dressing when needle is withdrawn.
14. Allow patient to lie flat on his back without a pillow for 12-24 hrs.
15. Keep patient warm and comfortable.
16. Observe patient for the next 24 hours for the following:
a. Leakage from puncture site, Headache, Backache and Vital signs, changes in the level of
consciousness, pupil size and reaction, respiratory status, numbness tingling sensation or pain
radiating down the neck.
17. Express appreciation to patient. Remove and dispose off equipment as appropriate.
18. Document procedure and ensure specimen is labeled and sent to the laboratory with the
request form.
19. Assess lower limbs for every 2 hours for signs and symptoms of paralysis.
20. Documentation; date and time of procedure, the physician name, patient tolerance, the
amount of fluid, colour any abnormalities seen, any strange behavior of the patient, and the
ranges of the vital signs and the level of consciousness.
Complications; severe headache, blurred vision, hematoma,
BONE MARROW ASPIRATION
This is the introduction of a needle directly into the bone marrow to obtained specimen for
histological examination. Bone marrow biopsy is the removal of a core of marrow cells for
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laboratory analysis; the marrow is examined in the laboratory to reveal the size, number, shape
and development of red blood cells. Culture of bone marrow can help differentiate infectious
disease such as tuberculosis. The specimen is taken from the iliac creast, the sternum, the spinus
process of the vertebrate and for children in the proximal tibia. During the procedure the
physician injects local anesthetic into the site for some time and inserts bone marrow needle into
the bone and aspirate bone marrow the needle is removed and pressure dressing is applied.
Indications: leukemia, malignancies, anaemia and thrombocytopenia
EQUIPMENT: A tray containing sterile bone marrow aspiration set: bone plaster, cleansing
lotion and a pair of scissors
Preparations
1. Explain the procedure to the patient and reassure him
2. Ensure patient signs a consent form
3. Shave the area hairy and clean with soap and water
4. Check vital signs and record
5. Check the patient coagulation status; the use of anticoagulant, platelets counts and
prothrombin test.
a. Premedication is given if ordered
PROCEDURE
1. Reassure the patients and provide privacy.
2. Clean the area well with soap and water.
3. Put the patient in the require position.
4. Wash hands and sent the tray to the bed side
5. Hold the local anaesthetic agent while the physician withdraws it
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6. Assist the physician throughout the procedure
7. Make the patient comfortable
8. Remove equipments, decontaminate sterile and store
After the procedure
1. Check vital signs 4 hourly and record
2. Observe patient closely for bleeding, swelling, tenderness and erythematic at the dressing site
3. Observe for signs and symptoms of infections
4. Note the characteristic for bone marrow aspirate; amount, etc
5. Assess the patient’s level of pain and serve the prescribe medication
6. Document in the nurses note the following; location of the bone marrow site, amount and
colour or the marrow aspirated, patient’s tolerance to the procedure, vital signs before and after
procedure, and any observation made at the puncture site as well as complications.
Complications; bleeding, infections and organ puncture.
ELECTROENCEPHALOGRAPHY (EEG)
This is a process of recording the electrical activity of the brain in a graphical form. It provides
physiological assessment of the cerebral activity. The procedure is performed by applying lead or
electrodes to the scalp with small needles. The recording is displayed on a graph paper.
Purpose
The main purpose EEG is detection of epilepsy. But is also used to diagnose cerebral conditions
like hemorrhage, tumours abscesses, and thrombosis, cranial nerve defect and central visual
defects. The procedure takes 1 hour to 2 hours.
Nursing implication
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 The procedure and its purpose are explained to the patient especially the patient should be
told that the procedure will not give any electrical current as given to mental patient in
mental ward (ECT-electric convulsive the therapy). But the test records the brain activity.
 Ensure that a consent form is signed
 Tell the patient who will perform the test and where it will be performed
 Tel the patient he will be asked to relax on a bed and electrodes will be attached to his head.
 Continue to reassure him that the electrodes will not shock him or not painful.
 Allow patient to verbalize his concerns or ask questions
 Shampoo patient hair to make it free from hair spray and creams and pomade
 Instruct patient not to take any stimulant like coffee, tea, cola drink, depressant or alcohol for
24hours before the test.
 Withhold anticonvulsants, tranquilizers, barbiturates and sedatives as ordered for 24 hours

before the test.
 Instruct patient not to take any medication
 Allay patient’s fear since mental tension can affect brain waves
 The patient empties his bladder before the procedure
 Check vital signs and record to serve as a baseline values.
 Ensure that pins, wig or any hair application is not on hair and jewelleries are removed
 The patient is asked to clean the hair and the scalp well before and after procedure.
 Sent patient to the unit at the appointed time to relax him
 During the procedure tell patient to close the eyes and hyperventilate for 3 -4 mins.
 Instruct the patient to look at bright flashing light for photic stimulation (opening and closing
of the eyes). (this evokes abnormal electrical discharges
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 After the procedure, help patient to remove electrodes from the hair.
 After the procedure, help patient to remove electrodes from the hair
 Encourage patient to have a complete bed rest
 Resume all drugs that are withheld before the procedure
 Return patient to the ward and make him comfortable
 Observe patient carefully for seizure activity.
COMPUTED TOMOGRAPHY (C. T. SCANNING)
CT scanning is an X-ray technique in a more sophisticated manner to give more precise details of
organs. It is 100 times more sensitive than ordinary X-ray method of diagnosis. It detects fine
structures and small changes in density of an organ. So it gives very accurate information
regarding any changes in tissue than normal tissue. The procedure takes about 15-45minutes.
Purpose
The benefit of CT scanning in imaging the three cavities of body like head, thorax & abdomen.
The size, shape, contour and density of organs in these cavities are accurately observed by CT
scanning. The Head CT scan detects cerebral lesion like haematomas, tumours, cysts, edema,
atrophy hydrocephalus& infraction of brain CVA, brain abscess and paralysis. The Body CT
scan detects lesions like tumours, cysts of lung, liver, pancreas& kidney. CT Scan machines are
very costly and are available in very few hospitals in Ghana; SSNIT, Komfo Anokye, 37 and
KORLE-BU hospitals.
Nursing implications
 The procedure and its purpose are explained to the patient.
 A consent form is signed by the patient.
 Patient is informed not to take alcohol, sedatives, sedatives, tranquilizers and tobacco 24
hrs prior to the test as they can alter the outcome of the result due to changes in
metabolism.
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 Fasting for 6 hours is done to prevent aspiration
 Inform patient about the injection of contrast medium and whether he has any allergy to
iodine
 Check vital signs and record
 Encourage patient to void before being sent to the radiology department
 If head scan is to be done, the patient is asked to remove all earrings, hairpins, and other
ornament.
 Assist patient to wear cotton gown and transport him to the radiology department
 Patient is maintained in supine position.
 In case of brain scanning ask the patient to perform various mental exercises such as
reasoning and remembering. This measures brain activity changes as various areas of the
brain are used.
 In case of abdominal scanning the patient is kept on low- residue diet for 2 days.
 During the procedure the patient is kept calm and quiet.
 Encourage patient to drink large volume of fluid to assist in the elimination of the
contrast medium from the body
 Observe the puncture site for bleeding or hematoma and apply pressure dressing.
 Documents in the nurse’s notes; the date, time, length and place the procedure was
performed. Note the patient tolerance of the procedure and his status after the procedure
as well as the route and dosage of the radioactive material that was administered.
Nursing of special patients
Caring for a patients with unconsciousness
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An unconscious patient is the one who is unaware of his surroundings and is incapable of
responding to sensory stimuli. The degree of awareness can be assessed by using the Glasgow
Coma Scale. The provdes an objective way to evaluate a patient’s level of consciousness.
1. Provide privacy
2. Explain every procedure to patient and relatives
3. Put patient in the lateral or semi prone position with head turned to one side
4. Establish and maintain airway by frequent suctioning
5. Administer oxygen when necessary
6. Remove denture if any, wash, label keep at a safe place
7. Maintain patients’ safety by keeping up side rails all the time.
8. Maintain good body alignment to prevent foot drop and other complications
9. Check vital sign 4 hrly and record or as indicated
10. Perform Glasgow Coma Scale assessment once or twice daily depending on the patient
condition.
11. Observe for twitching of any part of the body and document on a fit chart
12. Maintain accurate intake and output chart and balance it every 24 hours
13. Maintain personal hygiene by caring the mouth and bathing him twice day, soiled linen
should be changed regularly.
14. Change position of patient 2-hourly and inspect skin at each turn, especially skin over body
prominences
15. Observe bladder and bowels for retention of urine and faeces as well as incontinence.
16. Pass urethral catheter and if possible wear pampers for patients.
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17. Maintain nutritional status by administering the prescribe IV fluids and feed patient through
the NG tube with a nutritious fluid diet
18. Change linen immediately when soiled to prevent pressure sores.
19. Give the prescribed drugs and observe for any reaction and document e.g IVF, analgesics,
antibiotic and antihypertensive.
20. Give passive limb exercises at each turn.
21. Reassure patient and relatives.
22. Educate relatives on the patient condition and involve them in patients’ care.
Caring for a patient with paralysis
A paralyzed patient is patient with loss of feeling in any part of the body caused by diseases and
injury to the nerve supply.
 Nurse patient on a firm and comfortable bed
 Change patients position every 2-hourly and provide passive exercise at each turn
 Treat pressure areas every 4 hours
 Encourage patient to sit up much as possible with adequate support
 Maintain proper body alignment and support the patient with pillows
 Maintain personal hygiene and perform oral care and bathe patient at least twice a day
 Monitor vital signs 4 hrly depending on the condition
 Give nutritious diet through the NG tube, spouted cup and straw, take time to feed patient
with swallowing difficulty, the feed should be rich in vitamins and protein. The patient is
encouraged to chew through the unexpected side of the mouth
 Reassure patient and relatives. Involve relative in patient care in.
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 Maintain aseptic technique in wound care and any invasive procedure
 Catheterize patient for continuous bladder drainage and care for the catheter daily
 Monitor urine output and bowel movement
 Encourage fluid intake to prevent dehydration
 Monitor fluids intake and output every 24hours
 Apply diapers and change immediately when soiled, paying special attention to peri-anal
region.
 Ensure that the physiotherapy visits the patient regularly
 The foot is kept at right angel and supported with sand bags.
CARING FOR A PATIENT WITH CONVULSION/MENINGITIS TETANUS
Convulsion is a response to abnormal electrical discharges in the brain. It is more common in

children and can occur once or in series over time. A child with recurrence attacks may develop
brain damage which can lead to mental retardation.
PROCEDURE
1. Position the patient on the site
2. Barrier nurse patient if its meningitis or any other infectious disease condition.
3. Maintain a patient airway
4. Give oxygen when there is dypsnoea
5. Ensure a completed bed rest
6. Loosen tight clothing around the neck, chest and waist
7. Check and record vital sign hourly, 2hourly or 4 hourly depending on the condition.
8. Tepid sponge if febrile or when temperature is above 38 degree Celsius and provide warmth
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9. Ensure a conducive environment i.e. dark room and less noise.
10. The prescribe IVF should be administered and monitored
11. Monitor intake and output strictly and balance every 24 hours.
12. Observe for sign and symptoms of dehydration and circulatory overload
13. Reassure patient and relatives.
14. Administer the prescribed anticonvulsant, analgesic and antibiotics. Monitor for the desired
and side effort of the drugs and internee appropriately.
15. Educate patient and relatives about the diseases condition.
16. Explain every procedure to the patient and relatives.
17. Involves relatives in the care of the patient.
18. Monitor the patient condition by keeping a fit chart
19. Serve the patient with adequate fluids and nutritious diet and if patient cannot tolerate food
feed through the NG tube.
20. Perform neurological assessment.
21Assess the patient level of consciousness
22. Document every intervention in the nurse’s note
23. Protect patient from danger and injury by using side rails all the time unless when attending
to the patient.
24. Put padded spatula in the patient mouth patient gets attack
RADIOTHERAPY- DEEP X-RAY THERAPY
This is a special exposure to x-ray in case of malignant or cancer. The site of the cancer is
exposed to deep x-ray as per specification by the radio- therapist or cancer specialist.
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Nursing implication
 The demarcation of the area by specialist should not be removed by the patient
 The area of exposure should not be applied with any chemical, soap or antiseptics
 Hot and cold application should be avoided to the area of exposure.
 Adhesive tapes should also not be applied.
 A special cream provided by the department should be applied over the area
 The therapy in the mouth causes dryness and discomfort. The patient should be encouraged
to have more fluids and wash the mouth frequently.
 If the patient complains about pain in the mouth encouraged the use of lozenges or aspirin
gargles.
 In case of ulcerative growth when exposed to therapy, it causes more offensive smell and
discharges. Frequently dressing is required.
 The patient is encouraged to eat nutritious diet as the therapy causes loss of appetite,
vomiting and depression.
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CHAPTER ELEVEN
NURSING CARE OF PATIENTS WITH THE DISORDERS OF THE EYE
Specific pre-operative care of the eye
1. Orientate patient to his new surroundings.
2. Help him to express any fear regarding loss of vision
3. Instruct him to wear dark glasses if atropine drops have been used.
4. Maintain safe environment for the patient
5. Administer an enema if this has been ordered.
6. Prepare the affected eye by cleaning the skin of that side of the face the night before and on
the morning of surgery.
7. Trim the eye lashes using blunt-ended scissors covered with petroleum jelly (Vaseline) or
shave as required.
9. Educate the patient on post operative restrictions specific to his surgery.
10. Inform the patient that he will be wearing and eye pad and shield on the operated eye when
he returns from surgery and that he unaffected eye may also covered.
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Trimming of eyelashes
REQUIREMENTS
A try with the following:-
Gallipot with gauze swabs
Gallipot with normal saline
Curved eye lash scissors
Receiver
Vaseline or soft paraffin
PROCEDURE
2. Explain the procedure to the patient and help him sit comfortably in reclining position
with the head supported
3. Clean the eyelids with gauze swabs in saline if necessary.
4. Smear the blades of the scissors with Vaseline or soft paraffin on a swab.
5. Ask the patient to look down. Trim the upper lashes as short as is safe and practicable.
6. Ask the patient to look up and trim the lower lashes in the same way.
7. Clean from the nasal to the lateral aspect to remove pieces of eyelash.
8. If a lash floating in the eye you may need to irrigate it.
9. Dry the eye
11. Discard equipment
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13. Report any skin lesions or cuts on the eyelids. These might give rise sepsis in the post-
operative period.
14. Give the patient a light breakfast if surgery to be done under a local anesthesia.
15. Administer antibiotics and other eye drops or ointments as ordered by the doctor.
Specific post operative care of the eye
1. Nurse patient on his/her back or turn him to the un-operated side.
2. Restrict activities as ordered by the doctor
3. Announce your presence quietly when entering the patient’s room and explain all procedure
to him.
4. Secure the side rails on the bed to protect the patient form injury and provide sense of
security.
5. Place all bell or signal within easy reach on the unaffected side.
6. Keep the eye pad and shield in place
7. Report severe eye pain immediately.
8. Encourage patient to carry out deep breathing and leg excises he was taught pre- operatively
9. EYE IRRIGATION
Eye irrigation is used mainly to flush secretions chemicals, and foreign bodies from the eye, it is
also done to administer medications for corneal and conjunctiva disorders, to provide soothing
effect and before any operative procedure as ordered. The amount of solution needed to
irrigation an eye depends an eye condition, secretions require a moderate volume; major
chemical burns require a copious amount of fluids
REQUIREMENTS
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A trolley with the following:
Undine/ pipette/ rubber bulb syringe
Jug of lotion, e.g. normal saline at 38 or tap water can be used in emergency
Gauze swabs in a bowl
Towel and mackintosh
Two receivers
PROCEDURE
1. Explain the procedure to the patient
3. Set him comfortable in a reclining position with the head resting on the back of chair.
4. Protect the patient’s neck and chest with mackintosh cape and cover.
5. A second nurse hold a receiver in position against the patient’s check, or shown the patient
how to do this himself.
6. Warm the irrigation solution by placing the bottle of solution in a bowl of warm water
7. Test the temperature of the lotion with the lotion thermometer and then fill the undine or
pipette.
8. Gently separate the eyelids using the forefinger and thumb and ask the patient to look up.
9. Irrigate the lower fornix or the conjunctiva sac by drawing down the lower lid.
10. Direct the solution from a distance of 5cm or less and not directly over the cornea.
11. Ask the patient to rotate his eye periodically while you continue the irrigation
12. Inspect both the lower and upper eyelids for retained foreign particles
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13. After the irrigation is completed, dry the eyelids with cotton wool wiping from the inner to
the outer canthus, use new cotton for each wipe and the check with a towel before removing the
receiver.
14. For chemical burns, irrigate each eye for at least 15mins with normal saline solution
15. If after the procedure some medicine is required to be instilled or applied, do it
17. Clear trolley, wash and dry hands
18. Observe and record procedure /finding ; note the duration of the irrigation, the type and
amount of the solution , the characteristics of the drainage, the assessment of the eye before and
after irrigation and the patients’ responses to the procedure.
TAKING OF EYE SWAB
An eye swab is a swab taken from the conjunctivae in case of eye infection
REQUIREMENTS
A small tray with the following:-
Sterile swab in a test tube
A pair of disposable globes
Items for cleaning the eye
PROCEDURE
1. Explain procedure and rationale to patient.
2. Ensure privacy.
3. Sit patient up comfortably either in bed on a chair.
4. Ask patient to bend his head slightly backwards (may need a pillow to support his head)
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5. Wash and dry your hand and wear gloves.
6. Instruct patient to look up.
7. Gently retract lower lid.
8. Hold swab parallel to the corner rather than pointed directly.
9. Gently draw and rub swab along the lower lid from the nasal (inner) end out.
10. Return swab into test tube.
11. Report abnormalities.
12. If necessary bath the eye as described in procedure on eye bathing (irrigation)
13. Remove gloves and discard
15. Remove screen
16. Wash hands
17. Label and ensure specimen is sent to the laboratory with a signed request form
18. Record in nurses’ notes.
Note:
a. Ensure that swab is taken from the correct side e.g. where there is a discharge
b. avoid contamination by touching swab or the eyelid.
ADMINISTERING EYE DROPS
It is the act of putting into the conjunctiva sac of the eye. The eye is the most sensitive organ to
which the nurse applies medications; the corner is richly supplied with sensitive nerve fibres.
Care must be taken to prevent instilling.
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Medication directly onto the cornea, the conjunctiva sac is much less sensitive and thus a more
appropriate site for medication instillation.
REQUIREMENTS
Sterile disposable eye dropper, sterile cotton wool balls
A bottle of ophthalmic saline, paper towels and drugs as ordered.
Precautions
1. Work under a good lighting system
2. Clean eye always from the nasal corner to the outer canthus using each cotton wool swab
only once.
3. Pull down on the lower eyelid exerting downward pull over the skin of cheek bone if
eyelid are struck
4. Do not put presser to the soft tissue over the eye, only over bony prominences
5. Support your hands on the patient’s cheek when instilling into the eye. E.g. atropine apply
–pressure over pomatum for 30secs to prevent absorption into the tear ducts
6. Wait for a minute between drops if more than one drop is ordered and even if it is the
same drug. This is ensure the absorption of the drug
7. Give the thickest drops drug first
8. Apply eye ointment after eye drops if ordered.
9. Wash your hands before the procedure.
10. Inform the patient about the procedure and site effect occurring immediately or after the
procedure like atropine causing temporary impaired vision.
11. Turn the patient head to the site of eye to be instilled, so that any discharge will flow away
from the nose.
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12. Swab the eye starting from the inner to outer and use the swab once with a sterile cotton
wool swab soaked in saline solution to remove any discharge or previous ointments
13. Repeat the procedure for the other eye
14. Place a wool swab on the lower eyelid against the lid margin
15. Stand behind the patient and ask him to bend his head backwards looking up at you.
- Hold the dropper containing the eye drop or tube containing the ointment horizontally
while resting your hand on the cheek or the bridge of the patient’s nose.
16. Pull down the lower eyelid away from the eye ball and ask the patient to look up
17. Instill eye drop or squeeze 1cm of ointment inside the lower eyelid (conjunctiva sac)
18. Ask the patient to close the eye lid lightly so that the drug is evenly distributed over the
eye and wipe off the excess
19. Avoid touching the eyelid with dropper or tip of tube of other patients
20. If advised cover the eye with pad and bandage
21. Instruct the patient not to rub after application of eye drop or ointment
22. Record the procedure in patients’ chart
23. If any untoward effects, clean the eye with pain water and intimate the doctor
24. Documentation; record number of drops, time of administration, and eye i.e. left or right,
appearance before and after the procedure and patients’ response to the procedure.
APPLICATION OF OINTMENT TO EYE
REQUIREMENTS; ointment as ordered and sterile cotton wool balls
PROCEDURE
1. Follow general rules for administration of medicine and specific instructions on the
medicine.
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2. Explain the procedure to the patient.
3. Assist patient into correct position, head well supported and tilted back.
4. Wash and dry hands.
5. Clean eye gently with sterile cotton wool swab soaked in saline solution to remove any
discharge or previous ointment.
6. Wipe off tip of ointment tube after expressing small ointment and discard.
7. Place a wool swab on the lower of against the lid margin.
8. Retract lower lid and apply a line of ointment from inner to outer canthus.
9. Instruct the patient to close eyelids and rub his eyelid lightly in circular motion with
cotton ball to spread the ointment and record on treatment sheet.
10. Documentation; record number of drops, time of administration , and eye i.e. left or right,
appearance before and after the procedure and patient’s response to the procedure.
NOTES:
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CHAPTER TWELVE
NURSING CARE OF PATIENTS WITH EAR, NOSE AND THROAT DISORDERS
A nose, throat or sputum specimen is a simple diagnostic procedure performed for patient with
signs and symptoms of upper respiratory tract infections. They are collected from the patient
using a sterile swab. The specimen is placed in a culture medium to allow pathogenic organisms
to grow if they present a diagnosis can be made based on the analysis.
EAR, NOSE AND THROAT SURGERY
Pre- operative care
Specific preparation
1. Summon doctor to instruct the patient about the potential of hearing improvement and the
hazards of surgery.
2. Reinforce the doctor’s instruction about pore and post operative complications e.g.
disturbance of equilibrium.
3. Shampoo hair a day before surgery
4. Advise patient no to get out of bed 1st week post cooperatively without assistance.
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5. Advise patient to avoid nose blowing for at least one week after surgery. (this might blow
air into the Eustachian tube thus causing ear drum to be loosened).
6. Instruct patient on the proper way to blow the nose, blowing gently with nostrils
unrestricted and eyes open.
Post operative care
Specifics
1. Nurse the patient flat in bed, even the meals
2. Keep head movement at a minimum
3. Confine patient to bed for at least 24 hours
4. Discourage patient from watching fast moving objects e.g. television.
5. Perform passive exercise to improve circulation. Assist patient from lying to standing
position
6. Encourage patient to look straight ahead rather than look down. This helps him to
maintain his balance.
7. Record and report patient’s comments and findings e.g. ear, bleeding, sings of facial
weakness or paralysis (by: wrinkle his forehead, raise his eye browns, close his eyes or
show his teeth).inability to perform these activities may indicate facial involvement)
headache, nausea and vomiting.
Specific discharge instruction
1. Instruct patient to refrain from getting the dressing wet while bathing
2. Avoid sudden movements
3. Avoid riding in elevators
4. Avoid people with cold and cough (people who have upper respiratory tract infection)
TAKING A NASAL SWAB
196
It is a swab taken from the nasal cavity for laboratory investigation to identify the causative
organisms
REQUIREMENTS
Small tray containing:-

A sterile swab in its container put in a receiver
Sterile covered gallipot containing sterile water
A good light
A pair of gloves
A disposal paper bag
PROCEDURE
1. Explain the procedure and rationale to him

2. Provide privacy.
3. Send tray to bedside.
4. Sit patient up facing the light.
5. Wash and dry hands.
6. Put on gloves.
7. Ask patient to bend his head slightly backwards.
8. Remove swab from test tube and moisten slightly with sterile water. This not needed when
there is a watery nasal discharge.
9. Pass swab through the anterior nares then upwards inside the nose.
10. Rotate swab gently to obtain the specimen
11. Gently remove swab, put it into its container without contaminating it.
12. Remove gloves and discard into the disposable paper bag.
13. Make patient comfortable.
14. Remove screen.
15. Clear away equipment.
16. Label and ensure swab is taken to the laboratory with a signed request form
17. Wash and dry your hands.
18. Record and report procedure and your observations.
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TAKING A POST NASAL SWAB
This is a swab taken from the posterior wall of the nasopharynx in suspected carries of
meningitis or cerebrospinal fever. The oral route is used and special swab stick is used the west’s
swab.
This procedure is usually done under general anesthesia and therefore comes under theatre
nursing.
NASAL DROPS OR INSTILLATIONS
Patients with nasal sinus alterations may receive drugs by spray, drops, or tampoo. The most
common form of nasal drug is instillation which is a contestant use to relieve sinus congestion
and cold symtoms. Most of the nasal drops are antibiotics use for the treatment of sinus
infections.
REQUIREMENTS
Trays containing the following; cotton wool swabs, prescribed nasal drops, dropper and receiver
PROCEDURE
1. Explain the procedure to the patient and provide privacy.

2. Place him in the supine position with head extended, so that his chin is higher than his vertex.
3. Instruct patient to blow nose gently unless it is contain indicated.
4. Wash and dry hands, clean nostrils with cotton swab if necessary.
5. Draw up medication and instill by drops as ordered.
6. Ask patient to remain in position for about 5mins.
7. Ask him to breathe through the mouth and not to blow the nose.
8. Clean airway and drug that may drip from the nostrils with facial tissue.
9. Leave patient comfortable, wash and dry hands.
10. Record on the treatment sheet, clean and replace equipments.
11. Documentation; record the drug name, concentration, number of drops, nostril into which
drug was instilled and time of administration. Record patient’s responses in nurses note.
NASAL IRRIGATION OR ANTRUM WASHOUT
198
Irrigation of the nasal passage with warm normal saline solution soothes irritate mucous
membranes and washes away crusted mucus, secretions and foreign bodies. If these things are
left unattended their deposits may impede sinus drainage and airflow and cause headache,
infections and unpleasant odors. Route irrigation reduces the infection risk and increases comfort
and ease of breathing. The irrigation may be done with a bulb syringe or an electronic oral
irrigating device. Nasal irrigation benefits patient with chronic nasal conditions such as sinusitis,
rhinitis and those who regularly inhale toxins or allergens such as paint fumes, sawdust,
pesticides and coal dust
Contraindications; recent sinus surgery, advanced destructed of the sinuses, frequent nose
bleeding and foreign body in the nasal passages
TAKING A THROAT SWAB
INTRODUCTION:
This is a swab taken from the pharynx. It is usually taken in patient with conditions of the upper
respiratory, diphtheria bacilli and meningococcal. A pencil light is needed to illuminate the
throat and a tongue depressor for depressing the tongue so that the throat is clearly seen. It is
usually taken early in the morning before patient washes his mouth or takes a drink.
REQUIREMENTS
Tray with:
A sterile swab in a test tube
A spatula in a receiver to depress patient‘s tongue
Sterile gallipot with sterile water and covered
A good light (torch light)
A pair of gloves
PROCEDURE
1. Explain the procedure and the rationale to the patient a night before the test.
2. Wash hands
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3. Send tray to bed side
4. Provide privacy
5. Ask or help patient to sit up if possible on a facing the light
6. Wear gloves
7. Instruct patient to bend his head slightly backwards
8. Ask him to pen his mouth and put his tongue
9. Remove swab from its container
10. Moisten swab slightly with sterile water if a patients’ throat is dry
11. Depress patients’ tongue gently with the spatula
12. Pass swab gently through the mouth and rub it over the tonsillar area
Note:
Avoid touching the mouth and the tongue
An assistant may be needed to hold the light.
13. Withdraw swab and put it in its container
14. Remove gloves
16. Remove screen
17. Discard and clean equipment
20. Label and ensure specimen is sent to the laboratory with signed request form
Note:
If the patient is a child:-
1. Involve mother if present
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2. Let mother or a second nurse sit and hold the small child on the lap.
3. Be extra gently and friendly to win child’s confidence and allay his fears.
GARGLING
It is a simple method of washing out the throat usually with gargling fluid, warm water or saline
solution. the sound is produced by expelling air (Expiration phase) the cleaning solution remains
in contact with the mucous lining of throat to produce desirable effect. The solutions normally
used are
Warm or cold normal saline, potassium permanganate solution, sodium bicarbonate and weak
solution for tea.
Purpose
 To soften mucous membrane and wash out mucous secretion and other undesirable
discharge
 To relieve inflammations, congestion, swelling and pain
 To apply medicated solution locally
 To clean and promote suppuration in case of peritonsilar abscess.
PROCEDURE
1. The nurse arranges the solution and a drinking glass and asks the patient to do garbling
for a desired quantity of solution, may be hot or cold.
2. The hot solution is maintained at 105F and 107F
3. Arrange the solution in a glass and take it to the bed side of the patient
4. Instruct the patient to hold the solution in the throat as far as possible and then spit out in
bowl and repeat the procedure till the glass of solution is finished
5. Gargling should always be done in sitting or standing posture not in lying position.
TAKING AN EAR SWAB
201
An ear swab is taken from the outer
REQUIREMENTS
A small tray containing:
a) A sterile swab in a test-tube

b) A receiver
c) A pair of disposable gloves and a good light
PROCEDURE
1. Explain the procedure and rationale to the patient

2. Provide privacy
4. Sent tray to bedside
5. Put patient in a comfortable position with ear towards you
6. Put on gloves
7. Remove swab from container
8. Ask patient to relax
9. Hold pinna of patient’s ear upward and backwards- for the adult patients. If a child, hold ear
downwards and forwards.
10. Place swab into the outer ear and rotate gently to obtain swab without contamination.
11. Replace swab in its container and close firmly.
12. Clean ear if necessary (see dressing of the ear)
13. Remove gloves
15. Discard equipments
17. Label and ensure swab is send to the laboratory
INSTILLATION OF EAR DROPS
202
When administering ear medications the nurse not that internal ear structure is very sensitive to
temperature extremes. Failure to instill a solution at room temperature can cause vertigo severe
dizziness and nausea. Although structures of the outer ear are not sterile, use sterile drops and
solutions in case the dropper, because this can cause pressure within the carnal during the
instillation and subsequent injury to the eardrum.
REQUIREMENT
1. Sterile cotton wool swabs, to be used are safely covered
2. Medication should be close to body temperature
3. Place bottle of medication in water bath to obtain proper temperature, if necessary.
PROCEDURE
1. Assembly equipment and explain the procedure to the patients
2. Wash and dry hands thoroughly
3. Confirm the ear for the instillation by first inspecting unaffected ear then the affected ear.
4. Position patient in sitting up or lying with the affected ear up
5. Hold auricle upwards, backward (age 3 and less) downwards, backward and outward.
6. Clean external auditory carnal with sterile swab stick or wire wool carrier if there is a
discharge
7. Hold medicine dropper almost horizontally
8. Instill prescribe drops holding the dropper 1cm above the ear
9. Instruct patient to remain in lying down position with ear upward for about 5-10mins if
necessary. Apply gently massage or pressure to tragus of ear with finger this will move the
medication inward, if the medication is meant for 2 ears wait for 10mins before applying into the
other ear
10. Steady patient head to absorb excess ear drops.
203
11. Ask patient whether any discomfort is felt during and after instillation
12. Leave patient comfortable and record on medication sheet clean and replace equipment and
remain with patient for 5mins if a child, wash and dry hands
Documentation; record the drug, concentration, number of drops, time administered, any sudden
change patient’s hearing acuity and his response to the procedure.
EAR SYRINGING
Definition
This is gently flushing out of the external ear with solution to soften and remove wax, discharge
or foreign body. The procedure must be performed carefully to avoid causing the patient
discomfort or vertigo and to avoid increasing the risk of otitis external. Because irrigation may
contaminate the middle ear if the tympanic membrane is ruptured, an otoscopic examination
always precedes ear irrigation. This procedure is contraindicate when a vegetable foreign body
obstruct the auditory carnal because they are hygroscopic ie they attract and absorb moisture,
also if the patient has cold, fever, ear infection or an injured or ruptured tympanic membrane.
REQUIREMENT
At tray with following:-
Aura /Higginson’s syringe in a receiver
Jug or lotion (temperature 300) i.e. Normal saline
Pain water or sodium bicarbonate 1 teaspoon- 600mls of water
Lotion thermometer, Cotton wool in gallipot
Cotton bud Receiver, Mackintosh and towel
Additional requirements
204
Auriscope, Aural speculum, Aural forceps, Wax hook, Head mirror and lamp (it may be
necessary to put in some sodium bicarbonate ear drops or olive oil at least 4 hours before to
soften was)
PROCEDURE
1. Explain procedure to patient and seat him comfortably with the affected ear upward source of
light.
2. Screen patient and wash hands
3. Take tray to patent’s bed side
4. Place mackintosh and towel around the patients’ neck
5. Tilt the patient’s head slightly away from you
7. Check temperature of lotion and then fill the syringe.
8. Hold it upright to expel air.
9. Have patient hold the emesis bowl close to his ahead under the affected ear
10. Draw the inner of the ear upwards to straighten themaeatus
11. Steady the syringe against the thumb and direct stream of lotion against he upper border of
the meatus. (Do not insert the nozzle of the syringe into the canal)
12. The lotion will return bringing any was from the ear
13. Continue syringing gently until the returned fluid is clear
14. During the irrigation, observe the patient patient for sign of pain or dizziness. If he reports
either, stop the procedure immediately.
15. Dry the inside of ear with cotton wool on orange stick and outside with towel.
16. Stop procedure if patient complains of pain and inform the doctor
205
17. after the procedure, encourage the patient to lie on the affected side to encourage drainage of
residual of residual debris and solution thank patient
18. Clear away tray, screen, wash and dry hands
19. Document on nurses notes; note of duration of the irrigation, the type and amount of
irrigation solution, the characteristic of drainage, the assessment of the patient eye before and
after the procedure as well as this response to the procedure.
ASSISTING DOCTOR WITH ANTRUM WASHOUT OR NASAL IRRIGATION
Definition
Opening and cleansing the maxillary antrum to promote drainage and relieve pain.
REQUIREMENTS
A tray with the following:-
A receiver with Myles and Lipchitz Antrum trocar & canola
Higginson’s Syringe and A jug of normal saline (500-100mls)
A receiver with sinus forceps, nasal speculum dissecting forceps. Receiver for returned fluid,
Receiver for used forceps and receiver for used swabs
Cocaine spray, dressed flexible wine wool carried and Nasal speculum sponge e holding forceps
Lotion thermometer and Higginson’s syringe with adaptor and Specimen tubes Gauze swabs or
paper handkerchiefs and Mackintosh apron Jaconet apron/cover.
 NB: remind patient to keep his mouth open and to breathe through the mouth
 Instruct the patient not to speak or swallow
 Remove the irrigation tip from the patient nostril if he has to sneeze or cough
PROCEDURE
This is usually a planned procedure which is carried out on outpatient basis.
206
1. Reassure the patient and provide privacy.
2. Wash, dry hands and put on gloves
3. Sit patient up in chair.
4. Support patient in sitting up position with the head tilted back or extended until the antrum is
anaesthetized
5. Place jaconet cape/cover around patients’ neck.
6. Place tray at a convenient place.
7. Fill the Higginson’s syringe with normal saline temperature 38oc
8. Instruct patient to hold the receiver at chest level and incline the head forward so that as the
doctor dills the antrum the lotion may run out of the opeining of the antrum through the nose,
into the is.
9. Repeat the procedure until the return fluid is clear
10. Observe patient for pallor or faintness and return fluid for any abnormality e.g. colour,
viscosity, volume, us, necrotic material and blood
11. Dry patient’s face
12. Remove jaconet cape and cover
13. Place patient on a couch and allow him to rest for at least 2 hours or until he is well enough
to go home
14. Observe and report findings.
Instruct patient to clean nostrils daily with gauze swab moistened with normal saline
Ask patient to report to the hospital and to see the doctor for review wherever the need arises
and/or report for review as booked.
PAINTING OF THE THROAT
207
Painting of throat by a medicated solution is done in case of inflammation of throat to reduce
congestion and pain.
REQUIREMENTS
A tray containing a tongue depressor
A container with the desired amount of the solution
Kidney dish
Source of light
PROCEDURE
1. Inform the patient what you are going to do, why and what would b either result of the
procedure and how he would feel during and after the procedure
2. Take all the equipments in tray to bed side of the patient and keep it on a table or bed side
locker.
3. Provide source of light
4. Inform patient to open the mouth and depress the tongue with the tongue depressor
5. Dip the applicator in the solution and patient the tonsils and pharyngeal area gently and
quickly
6. Apply medicine only to the area ordered
7. Use each swab once and discard
8. Make an emesis bowl ready in case the patient wants to vomit
9. Instruct the patient not to wash mouth or take any drink or food within a reasonable
period of the time
10. Record the procedure.
NOTES:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
208
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REFERENCES
Allibone, L. (2005). Principles for inserting and managing chest drains. Nursing Times, Vol:
101, Is: 42, Pg: 45.
www.nursingtimes.net/nursing-practice/...skills/...drains/203599.article
Altman, K.W., Yu, G.P., & Schaefer, S.D. (2010). Consequence of dysphagia in the hospitalized
patient: Impact on prognosis and hospital resources. Archives of Otolaryngology-Head &
Neck Surgery, 136(8), 784-789.
Altman, B. G., Buchsel, P. & Coxon, V. (2000). Delmar’s Fundamental & Advanced Nursing
Skills. Dermar’s Thompson Learning
Bankhead, R., Boullata, J., Brantley, S., Corkins, M., Guenter, P., Krenitsky, J., Lyman, B.,
Metheny, N.A., Mueller, C., Robbins, S., Wessel, J., & A.S.P.E.N. Board of Directors.
(2009). A.S.P.E.N. enteral nutrition practice recommendations. Journal of Parenteral and
Enteral Nutrition. 33(2), 122-167. doi: 10.1177/0148607108330314
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Colodny, N. (2005). Dysphagic independent feeders’ justifications for noncompliance with
recommendations by a speech-language pathologist. American Journal of Speech-Language
Pathology, 14(1), 61-70.
Dennis, M.S., Lewis, S.C., & Warlow, C. (2005). Effect of timing and method of enteral tube
feeding for dysphagic stroke patients (FOOD): A multicentre randomized controlled trial.
Lancet, 365, 764-772.
El-Solh, A.A. (2011). Association between pneumonia and oral care in nursing home residents.
Lung. 189(3), 173-180.
Frey, K.L. & Ramsberger, G. (2011). Comparison of outcomes before and after implementation
of a water protocol for patients with cereberovascular accident and dysphagia. Journal of
Neuroscience Nursing, 43(3), 165-171.
Gomes, C.A., Lustosa, S.A., Matos, D., Andriolo, R.B., Waisberg, D.R., & Waisberg, J. (2010).
Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with
swallowing disturbances. Cochrane Database of Systematic Reviews. (11)DC008096.
Jackson, E. (2010). Wound Care – Suture, Laceration, Dressing: Essentials for Family
Physicians. AAFP Scientific Assembly.
http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/conf/assembly/
2010handouts/071.Par.0001.File.tmp/071-072.pdf
Leder, S.B., Suiter, D.M., Warner, H.L., Acton, L.M., & Swainson, B.A. (2012). Success of
recommending oral diets in acute stroke patients based on passing a 90-cc water swallow
challenge protocol. Topics in Stroke Rehabilitation, 19(1), 40-44.
Marik, P.E. (2011). Pulmonary aspiration syndrome. Current Opinion in Pulmonary Medicine,
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Marik, P.E., & Kaplan, D. (2003). Aspiration pneumonia and dysphagia in the elderly. Chest,
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Okada, S., Saitoh, E., Palmer, J.B., Matsuo, K., Yokoyama, M., Shigeta, R., & Baba, M. (2007).
What is the chin-down posture? A questionnaire survey of speech language pathologist in
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and respiratory complications in the elderly. Gastroenterology Research and Practice.
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in dysphagia secondary to acquired brain injury. A videofluoroscopy study.
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notification of usage to: hartford.ign@nyu.edu.
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211

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TABLE OF CONTENT

Dressing, removal of stitches and clips,

IV therapy, blood transfusion, parental, nutrition and intake and output

Chest aspiration, bronchoscopy, bronchography, cardiac catherization,

Barium meal, barium swallow, barium enema, endoscopy, proctoscopy, laparoscopy

Liver biopsy and abdominal paracentesis

Passing of NG tube, feeding through the NG tube, gastrostomy feeding,

Collection of specimen, 24hour urine collection, mid-stream urine collection,

Intravenous pyelography, retrograde pyelography, cystoscopy and peritoneal dialysis

Catheterization, catheter hygiene

Skin and skeletal tractions, and management of a patient with POP

Lumbar puncture, bone marrow aspiration, electroencephalography

CT scan of the brain, nursing of special patients and Radiotherapy

Eye swab and administering eye medications

Post nasal swab, nasal drop and instillation, antrum wash-out,

 To be able to describe the principles of wound healing.

 Recommend appropriate wound care and follow-up.

FUNCTIONS OF THE SKIN

 Regulates body temperature.

 Prevents loss of essential body fluids, and penetration of toxic substances.

 Excretes toxic substances with sweat (waste removal).

 Immunological function mediated by Langerhans cells.

Unintentional wounds- results from unexpected trauma…accident/ burns/ shooting. There is

Open -skin broken, portal of entry

Acute – goes through normal/timely healing process

Chronic – fails to go through normal stages of healing; no timely progress in healing.

Classification of wound healing

(According to the amount of tissue loss)

WOUND HEALING PROCESS

Wound healing usually goes through 3 main phases, these are:

 The Regenerative (Proliferative) phase

 The Maturative phase

THE INFLAMMATORY PHASE

 Redness- increased blood flow to the area

 Heat -metabolic activity occurring on the cellular level

 Oedema- phagocytosis and increased blood flow to the area

Blood vessels near the edge Begins 2-3 days of injury

Allowing excess - Resultant tissue filling is referred

Figure 1-4 Diagram of the regenerative process

THE MATURATIVE PHASE

CRITICAL WOUND HEALING PERIODS

Skin 5-7 days

Mucosa 5-7 days

Subcutaneous 7-14 days

Peritoneum 7-14 days

Fascia 14-28 days

Figure 1-5 Diagram of the critical healing periods

MODEL OF WOUND HEALING

Figure 1-6 Diagram of the phases of wound healing

WOUND HEALING CONCEPTS

 Surgical principles and wound prep

COMMON PATIENT FACTORS

 Blood supply to the area

Factors Influencing Wound Healing

 Good blood supply: ( oxygen, nutrients)

 Rest: skin cells multiply more rapidly during sleep

 Lack of stress: increased levels of adrenaline and steriods delay healing

 Age : children heal more rapidly than older people

 Site of wound: face and neck heal more rapidly