fundamentals of nursing notes key point quickly revision
IntroductionNursing - Derived → latin word
* Nursing is a unique function of Nurse
* It provide care to ill as well as healthy
ill → Curative & Rehabilitative
Nursing symbol - Lamp
First Researcher in Nursing:- Florence Nightingale
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Florence Nightingale:
- Born :- 12 May 1820. Place :- Italy
- When Florence Nightingale 3l year old. She started a nursing training course.
- 1853 : She completed a nursing training course.
- 1860 : She started Nursing Training Institute at Sent Thomas Hospital, Londan. Now This Hospital known as King Institute
- Death :- 13 Aug. 1910.
- Place :- 10th South Street London
- Pioneer of Modern Nursing → Florence Nightingale
- First Researcher in Nursing → Florence Nightingale
Health :- Defined by WHO - 7 April 1948 (Geneva)
- A state of complete Physical, mental, social (Harmonious R/S.) & spiritual well being (To believe in Supernatural power) & not merely the absence of disease or infirmity (Disability).
Infirmity (Disability/Divyang) - Differently Abled.
World health day :-April, 7
History taking & Physical examination
- A Process of data collection Information collection.
(1) Demographic data/Identification data.
- Age (To calculate the medication) gender, race, religion (To know cultural practice) & occupation (To know Occupational hazards).
Inorganic
- Coal-Anthracosis
- Silica - Silicosis
- Asbestos - Asbestosis (Cancer lung) Hey
- Iron - Siderosis
- Cane Sugar - Baggy
- Cotton - Byssinosis
- Tobacco - Tabacosis
- grain - Farmers lungs
- Coal miner's - Black lung
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- It should be Written in chronological order. First manifestation Should be written on top.
- O - Origin
- L- Location
- D - Duration
- C - Character/Course
- A - Aggravating factor
- T - Treatment triad
- S-Severity
(5) Family history
- (Pictogram) Family tree (Pedigree chart)
6.a . Immunization Status
- For pregnant women
- TT-I (as early as possible after the confirmation of pregnancy)
- TT-II (One month after first dose)
- Dose: 0.5 ml - I.M.
Rotavirus- Only Inactivated Influenza/polio vaccin
Varicella zoster:- I.M. allowed after 1 year
After MMR vaccination advice the woman not to be pregnant for the upcoming 1-3 month.
Hep. B. Vaccine - 0, 1, 6 month, No booster dose if titer level is > 10 MIU/ml.
Post exposure prophylaxis for non vaccinated Victims. (Hep B :-Dose of Immunoglobulin.)
Anti-D :- Gamma globulin to the mother 300ug. following delivery in Rh negative mothers within 72 hours
6.b School history
6.c Menses history:
- Normal Menstrual Pattern
- Menstruation Period duration
- During menstruation changes in body temperature :- 0.5-1.0°F temp
- During Ovulation changes in body temperature :- First 10.5-1.0°F temp. than 0.5-1.0°F temperature.
- Oligomenorrhea:- (long interval b/w menses) > 35 day.
- Menorrhagia:- (Excessive/prolonged bleeding) > 7 days +> 80ml
- Metrorrhagia:- (Irregular bleeding/bleeding b/w menses)
- Spotting/breakthrough bleeding Ex-Uterine fibroid.
- Endometriosis:- Growth of endometrial tissue outside the uterus.
- Amenorrhea:- Absence of Menstrual Cycle.
- Type of house & sanitation
- Physical examination of body is done by four technique
8.b Palpation
8.c Percussion
8.d Auscultation
8.a Inspection :- (Commonest)
By gross eye examination.
By microscopic (Instrument)
Exp.:-
- Culdoscopy:- To visualized pouch of Top douglas (pouch between uterus & rectum)
- Colposcope :- Visulization of vegina and cirvix
- Laryngoscope :- Laryngeal Examination
- Bronchoscopy :- Bronchioles Examination
- Arthroscopy :- A joint usually knee.
- Vascular Endoscopy :- Arterial & Vascular lumen
- Choledoscopy: - CBD (Common bile duct)
- Laparoscopy :- Abdominal organs
- Choledolithiotomy :- Common bile ductIncision (Stone renove)
- Palpate the Location, Size, Shape (Olive mass in pyloric stenosis)
- Assess the Temperature by dorsal surface of hand.
Ans. 99.6°F :- Increase by 1°F/0.5°C if Rectal, 97.6 F :- Decrease by 1°F/0.5°C if Axillary
Most accurate temperature - Rectal (< 6 year of age).
8.c Percussion :-Art to produce sound
Palpate to produce vibration.
Tapping the client's skin & body organs.
Percussion is Dull over liver & spleen. (Normal)
- 0:- No response
- 1+:- Sluggish or diminished
- 2+ :- Active or expected response.
- 3+:- Slightly hyperactive, more brisk than normal, not necessarily pathologic.
- 4+ :- Brisk, hyperactive 7 Intermittent clonus associated disease.
Emphysema:- Hyper resonance sound.
Thigh :- Flat sound
8.d Auscultation :
- Listening of Sound with equipment Stethoscope or another instrument.
NG tube :- Whooshing Sound.
PDA:- murmur
Dub :- Closure of semilunar valve. (S2)
Lub:- Closure of A.V. Valve (S1.)
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Order of physical Examination
- Inspection→ palpation → percussion →auscultation
- Inspection→ auscultation →percussion→palpation.
Turgor test - Pinch a large fold of skin & assess ability to return, poor turgor occurs in severe dehydration & extreme weight loss.
Snellen eye chart (20/20 feet) - For vision.
Confrontation/Perimetry test :- For peripheral vision. (Donder's Test)
Ishihara chart :- For colour vision.
When auscultating breath sounds, instruct the client to breathe through the mouth & monitor the client dizziness
- Abnormal lung sound called Adventitious sound
- Murmur :-(Gentle, blowing or swishing noise sound of heart)
- Rales or Crackles (Medium & Fine) In pneumonia
- Coarse crackles :- In pulmonary edema
- Wheezing - In asthma High pitched, during expiration.
- Rhonchi (Called sonorous wheeze) Chronic bronchitis, low pitched, loud snoring During expiration.
- Pleural friction rub :-In pleurisy, Coarse rubbing sound Throughout Inspiration & expiration.
↓
(Blowing, swishing sound)
Bowel sound :-
- Heard first in Right lower quadrant
- High pitched gurgling sound occurs irregularly for 5 to 30 times a minute. (Normal)
- Hyperactive Bowel sound :- Borborygmus sound (due to increased peristalsis).
Brudzinski Sign +ve - The client Passively Flex the hip & knee in response to neck flexion & reports pain in the vertebral column.
Decorticate posture -The client's arms (upper) are Flexed & held tightly to the sides of the body & the legs are extended & internally rotated.
Decerebrate posture -The client rigidiy extends the arms with pronated forearms & plantar flexion of the feet.
Disinfection, Sterilization & Biomedical Waste Management
Sepsis :- Infection - Invasion of PathogensAsepsis :- Free from pathogenic organisms.
Portal of Entry :- The routes are -
- Respiratory
- GIT
- Skin
- Genitourinary
Aseptic techniques :- Procedures used for asepsis maintenance.
Clean/Medical
- Body sterile & environment Contaminated
- Maintain=wards, casualties, Immunization Room, Hemodialysis
- For Injection, Vital sign.
- Bed making
- Hand Washing -40-60 seconds minutes.
- Flow of running water-Elbow to palm
- environment sterile & body contaminited
- Maintain=OT. ICU Critical care areas,
- For deep vein/arterial Catheterization
- For Urinary catheterization
- Hand Washing 3 to 5 minute But first case hand wash 10 minute
- Flow of running water-Palm to elbow
- Hand Washing : From less contaminated to more
- Soap :- Emulsification (decrease surface tension)
- Friction :-Heat production kills pathogens. it is most important Element
- Water
- Time
(1) Palm to Palm
(2) Palm to dorsal/Back.
(3) Interlacing fingers
(4) Knuckles.
(5) Rotation of thumb.
(6) Tip of fingers
(7) Wrist
Disinfection
Meaning :- Killing pathogenic microbes
Types :- There are two types Disinfection
- Concurrent -Ongoing
- Terminal- After discharge/death/ Transfer/Refer.
Bacteriostatic :- ↓ growth the bacteria.
Autoclaving :- Best method of sterilization in hospital.
Radiation :- Best method of sterilization at commercial level.(Garruma-Irradiated).
Sterilization
Meaning :- Process of killing of all king of microorganism (Pathogenic, Non-pathogenic, spores).
Types:
(1) Physical Sterilization
- Sun light. (Most cheaper) (U.V. Rays)
- Heat
- Dry - Flaming (Lab Slides) Burning.
- Moist
- Holder (63°C for 30 minutes)
- Flash (72°C/20 Sec. Methed)
Autoclaving :- 121°C/15 Lb/15-20 minutes ( 30 min )
S.S. Drum :-(Stainless steel) All Instrument put in this for autoclaving
- 30 minuten for wrapped articles.
- 20 minuten for opened articles.
- Drum window/ lids should be open, when going to CSSD.
- Close lids when coming back.
- Sharp instruments should not be sterilized by boiling because it decreases their sharpness.
- Once drum is opened than All the set of articles are used within 24 hours
- If drum is not opened than all the set of articles are used within 7 days
- Disinfectant :- Chemical agents used for cold sterilization
A . Cidex- 2% or 2.45% Glutaraldehyde
- note-Metals are not sterilized by chemicals because there is risk of staining of metals.
- Items to be disinfected
- Endoscope
- Humidifiers
- Nebulizer Tubings.
- It is available In Crystal form.
Ans.
What we want x Quantity / What we have
5 x 1000/100 = 50 ml (Phenol).
= 950 ml (Water).
Ratio of water & phenol is 950 : 50
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C. Sodium hypochlorite :- (strong disinfectant)
- Trade name: Polar
- Used concentration : 1%
- HIV +ve Instrument, blood, tubing. is disinfected by 1% Sodium hypochlorite.
- Available in: 5% & 10% solution
Q: Prepare 500 ml sodium hypochlorite solution 1%
Ans. 1%x 500/500 = 100 ml hypochlorite
= 400 ml Water
The efficacy of the prepared solution is only for 8 hours.
D. Savlon :- 5%
E. Spirit :- 70% Alcohol-Skin surface disinfectant / Thermometer clean.
F. KmnO4, - Potassium permanganate.
- 1:5000 to 1:10,000.
- Used for mouthwash.
- Used for Sitz Bath
G. Acriflavine 1%
H. Hydrogen peroxide (1:8) - Mouth wash.
I. Gentian violet 1%
Principle of Cold Sterilization :- Coagulation of Protein.
3. Gaseous Sterilization
Fumigation - In O.T.
(Produce formalin gas)
⇓
Formaldehyde + KmnO4,
FOR 12 Hours :- Close O.T.
New Concept :- Foggers - (Fogging) - O.T. Sterilize use of Echo Shield For 30 Minute Duration.
For 30 minute :- Waiting time.
Total :- 1 hours. (Case can be taken after 1 hour)
Exercises :- After sterilization the following can be used up to
Name
(1) Cheatle forceps Life Span→ 24 hour, In OT - 1 shift.
Bio Medical Waste Management
Meaning - Waste material R/T patient Care.
Categories :- 10 categories of BMW According to WHO
Sources :
1. Direct bedside
2. Causality
3. Laboratory
4. OT
5. OPD
- To prevent cross Infection.
- To prevent Nosocomial Infection.
- To decrease HCAI (Health care associated Infection)
- E.Coli - Common Cause of Infection in hospital
- Catheterization is most common procedure of HCAI India HCAI rate = 0.8 to 8% HCAI of ICU - 25%
- Common HCAI - UTI- E.Coli (Common Cause)
- Second common HCAI in Hospital - (Pseudomonas)
- Second common HCAI in community-Pneumococcus
(1) Generation :- Production of BMW
- Doctors & Paramedical staff are responsible for it
- A person who is generator is responsible for segregation of
- 48 hours (In ward = 24 hrs. in hospital = 48 hrs.)
(5) Disposal of waste
Categories of BMW bags
- Red → Plastic waste
- Yellow → Infectious waste
- Blue → Sharp
- Black →General waste
If plastic burns - Produce carcinogenic gases.
Dioxine :- Lethal to human body
Mutilation :- A process of alter the shape to prevent recycling
- Cutting of Hub of syringe
- Burning the tip of Infectious Needle.
- Chemotherapy needle should not mutilate because metal particle enter in respiratory system & cause cancer
Q.: For how much time hospital waste can be put in hospital ?
A. 24 hour - In wards.
B.. 48 hour - In hospital.
Universal precautions
- Used by healthcare providers, to prevent cross Infection.
- Efficiency :- 3 hours.
(2) Gloves
(3) Gown
(4) Mask
(5) Goggles
(6) Cap
(7) Shoe cover/slippers.
Universal precautions always depends upon nature of disease & nature of procedure.
Exercises:-
Q. During bed making.
Ans. Mask - Occupied bed.
- Gloves - (Close bed)
- Gown - Infectious patient
Q.: During dressing of wounds → Gloves, Gown.
- Burn wound → Gloves, Gown, masks.
Q.: Care of T.B. patient - mask.
- Intubation of T.B. patient - All needed.
Q.: During Catheterization → Gloves. (Sterile)
- No touch technique not remove wrapper
Q.: During bed bath :- Gloves.
Q.: Weight measurement - None.
note → Hand washing is must in All kind of procedures
Q.: Which is not an universal precaution used by nursing staff.
A. Mask
B. Hand washing
C. Cough etiquettes
D. Gown
ANSWER: C
Q: Pulse of T.B. patient taken then - Mask.
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Nursing Process
It is a systematic, scientific process, Have 5 steps- Assessment
- Nsg Diagnosis
- Planning
- Implantation
- Evaluation
- Head to toe/ Cephalocaudal/ Crown heel assessment.
- Newborn assessment - Keep newborn warm during examination.
newborn
- Length :-45-55cm (18-22 inch).
- Weight :- 2500-4000gm. (5.5-8.75 lb).
- Head circumference :- 33-35cm.
- Head - 1/4 of body length, 1/5 of body weight (adult).
- Chest circumference:- 30-32 cm
- If HC & CC more than 3 cm = macrocephaly
- If HC & CC Less than 3 cm = microcephaly
Caput Succedaneum
- Edema of soft tissue Over bone
- Crosses suture line
- Subside within few days (24 hours)
- Swelling caused by bleeding into area b/w Bone & periosteum
- Don't cross suture line.
- Absorbed within 6 week
these subsides spontaneously.
- Assess for Down Syndrome (trisomy 21.) -Single creases associated with Down Syndrome. ( normal two creases )
- Nasal flaring is an indication of respiratory distress.
- Seesaw respiratory pattern. (fall & rise of chest & abdomen don't occur togetherly).
- Billard scale :- Assessment of Gestational age
- Brande scale :- Assessment of Decubitus ulcer
- Glasgow Coma Scale:- Assessment of consciousness
- Eye movement, Verbal, Motor activity
- Minimum = 3
- Maximum = 15
- Coma = 7 & Below 7
Minimum=0
Maximum = 10
CAGE :- To assess/detect the severity of alcoholics. Eye opener drunker. > 2 - Indicate alcohol.
Nipple oedematous & often milky secretion (witch milk secretion)
Vernix caseosa (Responsible for evaporative loss of heat) presence of entire body in preterm newborn but is more prominent b/w folds closer to arm, may be absent after 42 weeks of gestation
Milia :- Small white sebaceous glands appear on the forehead, nose, skin.
Skin - Dry peeling skin-Post mature baby
Acrocyanosis :- Peripheral cyanosis of hands & feet is normal in the first few hours after birth & may be noted Intermittently for the next 7-10 days.
Harlequin sign :-Deep pink or red colour develops over one side of the newborn body while the other side remains pale or normal colour Indicate shunting of blood that occurs with a cardiac problem or may indicate sepsis.
Umbilical cord - Have A2, V2, upto 4 month of fetal life. after birth A2, V1, (A2, V1, is after 16 week)
Umbilical cord
- 40 cm length (30-100cm).
- 1-5cm Diameter.
- The right vein disappeared by 4 month.
- Battledore - Cord at margins.
- Velamentous - Cord at membrane.
- Small thin cord associated with poor fetal cord.
- Abdominal depression:- Diaphragmatic hernia.
- Abdominal Distension:- Obstruction /mass / sepsis.
- Abdominal Sound :- present in first hour after birth.
- Postpartum constipation may occur, c impaired bowel movement.
- Soft formed stool - by 2nd & 3rd postpartum day.
- Pseudomenstruation (Bleeding through vagina due to withdrawal of maternal hormone estrogen).
- First voiding- Should occur in 24 hour.
- Anus :- First stool meconium should pass with in first 24 hour.
- Normal length 45cm, Shape-little finger, Lumberpuncture:- Adult site- L3-L4, child- L4-L5
- Assess for hair tuft's & dimples along a spinal column (Indicate possible opening & NTD).
- A degree of hypotonicity & hypertonicity may indicate CNS damage.
- Allis sign/Gallaui sign :- Shortening of limb on affected side.
- + ve ortolani sign :- Abduction/Clicking Sound.
- + ve Barlow sign :- (Femoral head out of acetabulum)
- + ve Trendelenburg sign.
- Greater trochanter is prominent.
- Marked lordosis & waddling Gait.
(B) Congenital Club Foot :
- Talipes Varus :- Inversion/bending inward.
- Talipes Valgus :- Eversion/bending outward.
- Talipes Equina :- Plantar flexion-toe is lower than heel.
- Talipes Calcaneus :- Dorsiflexion - toes are higher than heel
- Talipes equinovarus :- most common
- Talipes equino valgus
- Talipes calcaneal varus
- Talipes calcaneovalgus
3 dimensional/Spinal deformity that usually involves lateral curvature, spinal rotation.
- + ve adam's test :- Asymmetry of Ribs & flanks is noted when a child is forward at waist & Hangs the arms down the feet.
- Lordosis (Swayback) - Ted lumbar curvature.
- Kyphosis (Hunchback)- Exaggeration of posterior curvature of thoracic spine.
- Scoliosis - lateral spinal curvature
- Pyloric Stenosis :- mass - Olive shape-right side to umbilicus :- wave - Lt. to Rt.
- Renal tumor/Nephroblastoma :- Don't palpate
- Epispadias :- Urethral opening at dorsal surface.
- Hypospadias - Urethral opening at Ventral surface.
- Cryptorchidism Undescended testes. Blum ele descon onlayn
- Blue colour of fingers - Raynaud's phenomenon,
- Ischemia + pain + ulcer => Burger's/ Smokers disease
2. Nursing Diagnosis
Meaning - Response of body to the diseaseExample :- Altered nutritional status R/t to loss of appetite.
• Qualifier's (increase/decrease/risk/altered)
• Diagnostic labeled.
3. Nursing Planning
It is setting the goal
Goal may be short term or long term.
Goal should be SMART
- S - Specific
- M - Measurable
- A - Achievable
- R - Relevant
- T - Time bounded
- It is putting the plan into action.
- It is determined to what extent the stated objectives have been achieved.
- Then decide to terminate or recycle the plan or modify the plan.
- Process ends with the discharge of the patient.
- Discharge planning starts at the time of admission.
Bed
(1)Closed bed :- For newly admitted clients.(2) Open bed :- Patient already is in bed but capable to move out
(3) Occupied bed :- Patient completely in bed, not able to move out.
(4) Cardiac bed :-For asthma Patient or for cardiac or respiratory problems.
↓
Upper end elevated & patient have support over cardiac table.
(5) Amputation:- lower half cradle bed. (Painprevention)
(6) Blanket/Cradle bed :- Burn patient, Oedematus & painful patient Kidney patient, Rheumatoid arthritis
Supporting devices
- Sand bags :- To immobilise body parts.
- Bed pan :- For defecation.
- Urinals - For urination
- Macintosh :- To prevent soiling of bedsheet, from shoulder to knee joint, put below 37 cm of head of bed.
- Call bell :- For assistance
- Bed :- 78x38x28cm. (Length, width, height)
- Hospital bed sheet :- 108 x 76 cm.
- IV. Pole :- 18-24 inch.
- Drawsheet :- To prevent skin irritation, 21cm.
- B/w 2 Bed Distance - 6 feet
Vital Signs - Also called cardinal signs that reflects the body’s physiologic status.
1. Temperature :- It is a difference between heat production & heat loss Measured in Centigrade or F- normal range are 37 degree C or 98.6 degree F
- Fever when body temp. more than 37.2 degree C called fever.
- In -Increased temperatur – Vasodilatation & sweating and hence decreased temp.
- In-decreased temperature - vaso constriction shivering
- Greatest heat loss up to 80%(60-80%)
3. Convection – it is transfer of heat away by air movement Eg- electric fan
4. Evaporation – it is the transfer of heat when substance change their medium Eg- Solid→ Liquid → Gas 22% heat loss
- 1 Kcal - 4.184KJ
- Thermogenesis- production of heat
- Heat metabolism organ = liver
- Thermoregulation center = hypothalamus
- By Metabolism=Anabolism+ Catabolism
- Anabolism = synthesis
- Catabolism = break down
Fever-
- Fever- Work act as defense mechanism : in our body
2. Fever also fight viral infection by stimulation “interferone “ which is a viral fighting substance.
3. FUO- Fever of unknown origin
Hyperthermia –Body temp.continue elevation & not heat loss mech.
S/S- Excessive thirst ( Early Sign )
Classification –
- Low Pyrexia- 99-100 degree F
- Moderate pyrexia -100-103 degree F
- High pyrexia -103-105 degree F
- Hyper pyrexia- >105 degree F
▪ Body unable to heat production
▪ Continue heat loss.
Sign- Uncontrolled shivering
⧫ If 34 C से body temp कम जा रहा है तो BP. heart & respiratory problem should be occur .
Classification-
1. Mild – 34-36.9 C
2. Moderate – 30-33.9 C
3. Severe-<30C
Type of fever-
1. Hectic or Swinging fever- जब Temp. के max. और mini. Time के बीच बहुत ज्यादा difference हो जाये. per 24 hour count होता है
2 inverse fever -Normally - Evening temp > morning. temp.
⧫ But in inverse- Fever –Mng temp > Evg. Temp.
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3.Crisis -Two type (high temp. वाले fever का कुछ समय बाद कम हो जाना)
A) True crisis- in this Temp. decrease & Pt.Condition is improve.
B) False crisis- in this Temp. decrease but also condition of patient is not improve .this is medical emergency.
4. Lysis-( Zig-Zag manner).
In this zig-zag manner temp.is lysis.
5.Constant fever- (2C or 3.6F) इसमें Temp. 38 degree C से ऊपर बना रहता है लेककन Mng & evg temp decrease (2 degree c) से अधधक अांतर नही पाया जाता
6. Remitent Fever- [Spikes(spiky hair) & falls fever]
In this fever mng.&evg. Temp. difference is more than 2-3 C but in evg. Time does not return to normal condition.
⧫ Intermittent or quotidian fever- in this Temp. is decrease & return to normal acceptable range with in 24 hour.
⧫ Opposite of constent fever- Remitant fever
⧫ Rectal thermometer insertion point-
- Adult -3.5 cm( 1.5 inch)
- Infant-1.2 cm (0.5 inch)
- Direction – introduction into rectum towards the umbilicus.
Temperature-
Oral 98.6 F (2min)
Rectal – 99.6 F(3min)
⧫ Thermometer-
(A) Tymponic membrane thermometer- (Core temperature)
▪ Most accurate method (2.5 sec)
▪ 1/3 part insert.
▪ Most reliable method – Rectal method
▪ Boling point 35.7 C
▪ Freezing point 39 F
Mercury is 13.5 time heavier than water.
✓ If client take hot & cold liquid & cigratte smoke wt.for 20 mins for measuring temp.
Heat loss by Radiation – Maximum heat loss up to 80% Conduction
Convection Evaporation
Normal tem – 37 c or 98.6 F.
37.2 c – indicate- fever
Types of body tem.
- Core tem – Oral, Rectum
- Surface – Axilla
- SDA of Protein - 30% (Highest)
- Mixed food - 12%
- Fat - 4%
- Carbohydrates- 5-6%
- 1gm fat :- 9 Kcal - 38KJ.- Highest source of energy. most dense source of energy
- 1gm carbohydrate :- 4 KČal.-17KJ-→ Most readily available
- 1gm protein :- 4 Kcal.-17KJ.
- Respiratory organ - lungs.
- Respiration - 16-20 respiration per min
- Tachypnoea = >24 respiration /min
- Bradypnoea - < 10 respiration /min
- Hyperpnoea :- Deep respiration
- External respiration :- Process of Inhaling & exhaling air & diffusion of gases between alveoli & capillaries.
- Internal respiration :- Process of exchange of gases between capillaries & cells
- Inhalation - 25Sec.
- Exhalation 30 SEC.
Absence of Respiration :- Apnea
Sound:-
Wheezing :- Asthma- COPD,
Crackles :- TB pneumonia.
Ronchi :- Pneumonia & T.B.
Pleural friction Rub :- Pleurisy.
Cheyne stoke respiration :- Rhythmic with periods of apnea.
Kussmaul Respiration :- Respiration rate are abnormal, deep, Irregular i.e. DKA
Cyanosis :- Bluish discolouration of skin
Anoxia/Hypoxia :-O2↓, at tissue.
Hypoxemia :- O2↓, at blood. Methods of detection of hypoxaemia.
(1) ABG analysis (most accurate)
(2) Pulse oximeter :- O2 saturation in blood (96 -99%) 100% when patient is on ventilator
Ventilatator modes :
- Time cycle :- (Pediatric, neonate).
- Volume cycle
- Pressure mode
- Wheezing - Bronchospasm
- ↑Secretion
- Obstructed tube
- Tube biting.
- ET tube displaced
- Disconnection or leak in Ventilator or tubings
- Stop spontaneous Breathing
Pneumonia :- Crepitus (Subcutaneous emphysema).
3. Blood pressure
- Definition :- Pressure of blood against blood vessels.
- Systolic :-During contraction of ventricle
- Diastolic :-During relaxation of ventricle
- B.P = 120/80 mm Hg. 16/11 Kpa
- Hypertension :- >140/90 mm Hg.
- B.P=C.O.x PR (CO = SVx HR)
- B.P. = SVx HR xPR (PR :- Resistance against the blood flow).
- SV = 70 ml HR = 72 bpm
- C.O. = 5 ltr
- Pulse pressure = Systolic blood pressure - Diastolic blood pressure
- Normal pulse pressure is 40mm Hg
Orthostatic hypotension :- B.P↓ when Position Changed. it decreases when person sits from supine or when stand from sitting,
BP decreases :- Supine /lying → Sitting → Standing
Orthopnoea→ Classic Symptom of left side heart failure. (Difficulty in breathing when lying.)
Q. A orthopneic patient comes to the hospital with a position given
ans-semifowler
Q.: Position given to Hypovolemic patient
Ans. Trendelenburg.
B.P. measurement:
- Instrument :- Sphygmomanometer
- Site :- Above antecubital fossa (2-3 cm Above) :- Take Brachial pulse
Special consideration r/t with blood pressure-
1. If bladder cuff too wide/ loose - False low reading
2. If bladder cuff to narrow /short /tight - False high reading
3. If the arm low the heart level - False ,high reading
4. If the arm above heart level - False, low reading
Normal B.P reading in thigh are higher than upper extremity
B.P. measure in thigh are lower than bronchial pressure indicates arterial disorder.
B.P. नापते time korotkoff नामक sound सुनाई देता है
Patient :- A person who is not healthy.
Client :- A person participates in health care services.
Customer :- Avail the services & pay for it.
Admission :- Allowing a client to stay in hospital./ offer the bed.
Admission may be :
1. Routine admission
2. Emergency admission.
Requirements for admission of a client
- Basic Informations :- Name, age, religion, address
Urine Sample
- Midstream sample.
- Morning-bed time
Single sample/ (100-120 ml urine) - At room temp.
1. One time sample -No need of preservatives
- If delay in sending, keep in refrigerator
- Try to send immediately in Labs
Add preservative Boric acid Chloroform HCI
- First collected urine should be discard
- Collect for next 24 hour
Normal characteristics :
(1) PH - 4.6 to 8 (Acidic to alkaline)
(2) Specific gravity - 1.016 to 1.025
(Specific gravity is the Concentration/Dissolve particles)
H2O ↑ → Specific G↓
H2O ↓ → S.G.↑
Exercises :- Specific gravity of urine
i) In brun - ↑
ii). Cardiac failure - ↑
iïi). Diabetes Insipidus - ↓
iv). Diabetes mallitus. - ↑
v. Overhydration -↓
vi. Dehydration - ↑
vii. Renal failure - ↓ Initially - Electrolyte not reabsorb.
(3) Composition of urine :
96% - H2O
2% - urea
2% - uric acid, electrolyte, creatinine, chloride, phosphate, sulphate, oxalate
(4) Volume - 1500ml.
Polyurea - Increases volume - DM & D.I.
Severe oliguria < 100 ml
Oliguria - < 400ml/day - Kidney failure
Anuria < 50 ml/day or Absence of urination.
(5) Urine Colour-Amber colour.
Bone marrow → RBC.
↓
Hb.
↓
(Heme) fe + Globin (Protein) - Utilise by body for growth.
↓
Biliverdin
↓
Converts in to Bilirubin, in presence of Biliverdin Reductase
↓
Conjugated bilirubin. (IN LIVER) Water soluble (Mono & Di glucuronic acid).
↓
Blood
↓
GIT
↓ ↓
Urobilinogen Stercobilin.
↓ ↓
Urine Stool.
↓ ↓
Amber colour. Pale brown colour.
Pale/yellow color of urine - Normal.
(i) Green colour urine :- Bile pigment ↑se.
(ii) Red colour urine :- Hematuria (Bleeding. RBC)
Drug: Pyridium
(iii) Orange colour :- Rifampicin drug (Anti T.B. drug)
(iv) Turbid :- Pus in urine.
(v) Whitish/Chyluria - Milky whitish urine.
- Filariasis, Due to ↑ed fat.
Hematemesis - Blood in vomiting,
Malena - Blood in stool
(6) Odour- Aromatic (Normal)
In diabetes mellitus & In DKA
Fruity odour :- Acetone present in urine.(Rothera's test.)
Urine test in Laboratory:
(1) Proteinuria - Hot & Cold test
↓
Protein in urine :- In Nephrotic Syndrome. Hypoalbuminemia
Q.: Hot & cold test is used to detect.
A. Amino acid in urine By product of protein breakdown.
B. Globulin in urine - Immunoglobulin use,
C. Albumin in urine
D. All of above
ANSWER: C
(2) Glycosuria :-Glucose in urine
Benedict's Test -
- Blue liquid c̅ no deposit - Absence of sugar Green liquid c̅ no deposit - Approximately 1% sugar.
- Green liquid c̅ yellow deposit - Approximately 2% sugar.
- Colourless liquid c̅ orange deposit - Approximately 3% sugar.
- Brick red :- 5% or above. DM
Nitroprusside test. (Na- Nitroprusside used for test)
(4) Bile pigment :- Smith test → Green colour +ve.
(5) Bile salt :- Hey's test.
Sterile technique of urine sample
Catheterization
- In Menstrual Cycle
- In UTI , In unconsciousness patient
- Catheterization: Sterile technique
- By close technique.
Stool Specimen
indication
GIT Infection.
Parasitic Infection.
Infectious disease- cholera, Typhoid
Characteristics
Normai : -
- Semisolid
- Smell :- Pungent due to present of skeleton
- Brownish colour
Clay colored stool :- In biliary obstruction (Stercobilin absent).
White stool :-Due to barium diet Intestire.
Red stool :- Malena
Watery stool + mucus + blood - Dysentery.
Rice water stool :- Cholera
Pea soup stool :- Typhoid (Salmonella typhi. Step Ladder pattern fever.)
Widal test (Confirmatory test)
Tarry Red colour stool. :- In upper GI bleeding.
Black, bloody :- Colon cancer
Ribbon shaped stool :- Hirnshprung's disease,
Megacolon (Intestinal obstruction)
↓
Postganglionic nerve fiber Absent. (Aganglionic colon).
Jelly stool :- Intussusception
Q.: Fresh red colour-Lower GI bleeding.
Ans. (In colon cancer)
Watery Stool :- Diarrhoea (3-4 time)
Q.: When Diarrhoea condition persist for a longer time → Metabolic acidosis.
Q.: Typhoid Infected clothing should be dip in which
-Solution [Phenol = 5% Carbolic acid.
More high fiber diet = Dumping syndrome, characterized by lightheadedness, fainting.
less fiber diet :- Cancer.
Constipation :- Difficulty in passing stool or Absence of stool
Obstipation :- Stool retention in intestine for a longer interval
Achalasia :- Decrease movement of oesophagus
Food stay in stomach :- 3-4 hours
Maximum retain :- Fat.
In fiber diet :- Within 1/2 hours stomach empty
↓
If high fiber diet is taken then Dumping syndrome may occurs. It is characterized by Hyperosmolarity Water from blood enters in to intestine & causes Rapid heartbeat Hypovolemia, Dehydration. Sweating, abdominal pain, Nausea.
Sputum Sample
Requirement:- 15 ml
Colourless secretion of respiratory tract.
Abnormal findings of sputum are:
(1) Yellow - Pus present
(2) Red - Blood in sputum (Hemoptysis).
(3) Black - Carbon pigment, Smoking, pollution
(4) Green - Bronchiectasis. (Dilatation/widening of Respiratory bronchioles. )
(5) Rusty - Pneumonia.
(6) Brown - Gangrene of lungs.
Q.: In Sputum Acid fast bacilli (AFB) + ve, Then which therapy should be started
Ans. DOTs therapy
- AFB:- Mycobacterium tuberculosis.
- 24 March :- International T.B. day.
side effect of DOTS- Vision problem :- Ethambutol.
- Neuritis :- Isoniazid
- Give (Bit B6/ Pyridoxine) to overcome the neuritis side effect of DOTS
Q. Eosinophils present in sputum -- Asthma
(Allergic) - IgE↑se.
Collection of sputum :
(1) Time - Early morning, before brushing & breakfast
Mouthwash by plain water may be allowed
(2) Technique- Deep coughing - Deep breath & then Cough.
fundamental of nursing quiz-https://www.nursingofficer.net/2021/03/fundamental-of-nursing-quiz.html
Vomitus Sample
In G.I. Infection & abnormalities.
Vomiting
1. Projectile (forcefully) - CNS Infection , Pyloric stenosis, Hydrocephalus
2. Non projectile -Nauseated , Travelling, Indigestion
Haematemesis : - Blood in vomiting,
Light brown vomiting - HCI breakdown Hb.
Green :- Presence of bile (Bile Stained vomiting)
↓
In duodenal atresia.
Alkaline PH of vomit :-Induce by lower G.I.T.
Acid (HCI) comes out then in body :- Metabolic alkalosis
Q.: Severe prolonged & Continue vomiting may lead
Ans. Metabolic Alkalosis.
Hyperemesis Gravidarum - severe vomiting In pregnancy
Blood Sample
Blood Sample- (3-5 ml)
1. Venous blood -Routine Investigation
2. Arterial blood-For ABG analysis (Arterial Blood gas)
3. Capillary blood required for
- Glucose test
- Malaria Slide
- Rapid HIV test
- In pregnancy
- For blood grouping
- Hb estimation
Cannula :
Colour Size -Less Size, more diameter.
Orange- 14G Dialysis.- 240ml/min
Syringe :- Barrel, Piston, Hub.
2ml, 5 ml, 10ml, 50ml
Spirit :- Disinfection of skin before taking sample (70% Alcohol)
Single stroke technique for cleaning of skin.
Don't recap the needle after taking blood sample
Technique for recap - Single Scoop technique.
Don't bend needle, Mutilate needle.
Biopsy :- Specimen from living body. Preserve 10% formalin
Autopsy :- Sample from dead tissue.In postpartum
Comfort & Positioning
- To ensure comfort.
- To minimize bed sore.
- To prevent complications.
- To give medication.
- To do procedures.
Exercises:
Postioning in the following procedures
TPR :- Supine/Dorsal
B.P. :- Supine/Sitting (In pregnancy strictly in supine position) :- leg separate - Knee flexed.
Catheterization :- Female = Dorsal recumbent, Male = supine with leg abducted
Enema :- Left lateral
Pelvic surgery :- Trendelenberg.
Deep respiration - Fowler's position.
Rectal temperature : - left lateral.
Sigmoidoscopy :- Knee chest position.
Position change to prevent bed sore :- 2 hourly.
Type of positions
(1) Supine :- Person lies on the back.
(Dorsal) - For physical assessment
• Inspection
• Palpation :- Pulse, Abdomen liver palpate.
• Auscultation (Sound listen).
• Obstetrical Examination of abdomen.
- Recumbent (Fundal length).
(2) Dorsal recumbent :- Knee flexed, leg separate.
• For catheterization , Vaginal examination
(3) Fowler position/Sitting position.
- Cardiac cr Respiratory Problem.
N.G. tube insert-High fowler - 80°-90°
N.G. tube feeding-Semi- Fowler - 450-60°
low fowler - 30°
[Thyroidectomy, mastectomy]
Cardiac position :- Rest forward on cardiac tabel.
Fowler position :- Rest backward , not leaning.
GERD'S :- Reverse trendelenburg position.
- To promote gastric emptying.
- To prevent esophageal refluxes.
4. Side lying :- Lateral position
• To relieve supine hypotension in pregnancy.
Right lateral
- After liver biopsy.
- After feeding a child.
Left lateral
- during liver biopsy
- Enema
- Rectal temperature
- Suppositories
- Vaginal /vulval examination
Hemorrhoidectomy :- Lateral (Side lying) - to prevent pain & bleeding.
Q.: Rectal temperature of a patient is 38°C, then axillary temp is
Ans. 37°C.
- Rectal thermometer - Short & flat bulb.
- Semi Prone/Forward sidelying.
(5) Sim's position :- Lateral + prone.
- Same Indication as left lateral.
- Modified Sim's :- Cord prolapse.
(6) Standing position:-Physical Examination (Height)
Q.: A newborn length is measured in which position
Ans. Supine
NOTE-45 cm
- - Umbilical cord
- - Phototheray distance
- - Spinal cord - Evacuated Enema can height
- - length of newborn
(7) Knee Chest position
Cyanotic heart disease.
(TOF) - Cyanotic Spells (Tet's spells).
Shunt in TOF:- Blalock Taussig Shunt = Subclavian & pulmonary artery
- Waterston shunt :- P.A. & Ascending Aorta.
- Pott's shunt :- P.A. & Descending Aorta
• Cord prolapse.
• Sigmoidoscopy
• Postpartum exercise.
• Rectal examination
(8) Trendelenburg position:- Elevate the lower part of the body at almost 30 degree angle.
• If burn of face & head.
• Elevate the head end to prevent edema.
• Legs are elevated
• Head end is lower.o
. Indication - Burn severe dehydration
• Shock (hypovolemia)
• Cord prolapse
• Pelvic surgery (lower abdominal surgery).
•Appendicitis.
• Abruptio placenta. Post partum haemorhage.
(9) Prone Position - Lying on abdomen.
• NTD (Spina bifida).
• Post - anaesthesia.
(10) Lithotomy
• Delivery/labour (eutocia)
• Vaginal/vulvar exa.
Exercises:- Write the Position in the following situition
Q.: After seizure
• Lateral
• Supine with head turn to side.
Q.: A Patient is on the procedure of thoracentesis
Ans. Fowler
(Sitting) = Semi fowler position (Due to the principle of gravity).
Q.: A Pt. is on abdominal tapping procedure
Ans. Semi fowler's position
Oxygenation :- fowler's position.
Epistaxis :- Sitting c̅ head flexed & nose pinching
N.G. Insertion :- High fowler c̅ sip's of H20 for Swallowing
N.G. Feed :- Semi fowler's
Newborn Resuscitation
Restoration of vital signs
(1) Position - Supino with neck extension,
(2) Tactile Stimulation :- Stroking,
Heel too big too :- 1 finger stroke gently,
(3) Free flow oxygen :- Bag & mask.
Suction :- Oral first, then nasal,
- Pinch Suction catheter during Exertions
- (To prevent injury from -ve pressure)
- Remove catheter by rotating movement.
Administer Humidified air
Humidifier should be changed after 24 hour,
Humidifier should be disinfect in
- Glutaraldehyde (2%)
- Sodium hypochlorite (1%) .
Don't Top-up humidifier
Humidifiers fill up to 2/3.
Oxygen toxicity
RLF (Retro lanteral fibroplasia)
Combustion-fire
Atelectasis - Collapse of alveoli
(4) CPR
1 Minute :- 100 compression, 30 Respiration
Depress sternum :- 1.5 inch
Lower 1/3 of Sternum should be depressed. It is marked by an imaginary line drawn between both nipples, & provides the compression below this line.
(5) Endotracheal Intubation.
position- Supine c̅ neck extended.
(6) Life Saving drags. :- Adrenaline (Dilution: 1:10,000)
- Dopamine.
Comfort of patient
- Noise :- Normal 85db.
- Ear Frequency :-20-20,000 Hz
- Room temperature :-- 20-22°C
- Humidity: - 40-60%
- Exchange of air :- 15-45 feet/min.
- Noise in ward :- 25-35 decibel.
- Pressure :- Negative pressure (In case of communicable disease, Infectious disease, need Isolation) Eg:- T.B.
Comfort devices :
(1) Bed - Complete =Cot+bed sheet + another sheet.
- Metallic-78 x 38 x 28 inch
(2) Mattress :- Dunlop fibres
Air/water mattress :- For thin & obese patient.
(3) Bed sheet :- 6 Folded
- Metered corner
- Wrinkle free :- To prevent bed sore.
(4) Mackintosh :- To prevent soiling of bed sheets.
- From shoulder to hips.
(5) Bedspread :- Counterpan = To cover the bed.
- In closed bed
- To prevent dust.
Orthopneic position :- Leaning forward & sitting.
(6) Cradle :- To prevent the pressure of top sheets& blankets.
Used in :
Burn
Rheumatoid arthritis
Kidney failure (edema)
In open fracture.
(7) Pillow
(8) Locker
(9) Call bel :- In case of any assistance :- for safe and security (2nd level of maslow's theory)
(10) Cardiac table :- To provide cardiac position.
(11) Sand bags :- To immobilise body parts.
(12) Air cushion :- To prevent bed sore.
(13) Foot rest :- To prevent foot drop (Plantar flexion)
(14) Bed blocks - To elevate any part of bed. (foot or head end).
(15) Urinal:- For urination
(16) Bedpan - For defecation
Diet
1. Therapeutic Diet :-Diet specifically used to treat a particular deficiency or treat the disease
2.Clear liquid diet :-Transparent & liquid at body temperature.
- Given in :- Dehydration, gastroenteritis, pancreatitis.
- It is a deficit in energy (Calories) & nutrients.
- Dairy product & fruit juice
3. Full liquid diet :-Opaque & liquid at body temperature.
- Deficit in energy & nutrients.
4. Mechanically altered diet :-Altered texture of food for minimum chewing.
- Given to pt :-Dental problem, dysphagia, surgery of head or neck
5. Soft diet :- For difficulty in chewing & swallowing.
6. Low residue, low fiber diet :-In ↓ed G.I. motility In Inflammatory bowel disease, obstruction of GIT.
- Diarrhoea & GI problems.
7. High residue, high fiber diet : In constipation, irritable bowel syndrome, diverticulosis.
- Fruit, vegetables & whole grain products.
8. Fat restricted diet :
- In steatorrhoea, flatulence, diarrhoea due to high fatly diet, malabsorption disorder, pancreatitis, gall bladder disease , GERD.
9. Liver cirrhosis patient :-High thiamine (Vit B1) diet is given eg-Pork.
- High calorie, high protein diet
- HIV, AIDS, COPD, burn, stress, cancer, wound healing
10. Carbohydrate consistent diet :
- In D.M, hypoglycemia, hyperglycemia & obesity.
11. Sodium restricted diet :-Summer squash (Fruit & vegetables)
- In HTN, heart failure, renal disease, cardiac & liver disease.
12. Protein restricted diet :-In renal & liver disease. Especially Failure cases.
- Limit milk, meat, bread
- Give less protein diet to provide essential amino acids.
13. Renal diet :- for ARF & CRF
- Controlled amount of all electrolytes, Na+, protein & fat & fiber.
- Dialysis restricts fluid in most patients.
14. Potassium modified diet :
- Low potassium diet :- In hyperkalemia, In impaired renal function, hypoaldosteronism, Addison's disease, ACE Inhibitor drugs, Immunosuppressive drugs, potassium sparing diuretics.
15. High K Diet : In hypokalemia.
- In renal tubular acidosis, GI losses Diarrhoea, Vomiting, Intracellular shift, K+ wasting diuretics, antibiotics Hyperaldosteronism, Cushing syndrome, exogenous corticosteroids.
16. Low purine diet :
- In gout, Kidney stone (Uric acid, 2.5-8mg/dl)
17. Vegetarian diet
- Orange & dark green leafy vegetables have iron.
- Iron absorption given Vitamin C should be given with it.
BM = Weight(Kg) divaid by Height(M2)
Enteral nutrition
- Provide liquified food into GIT via tube.
- In client c̅ swallowing problem, burn, major trauma, severe malnutrition.
- If lactose (milk) Intolerance; give lactose free formula diet.
Parenteral Nutrition
Total PN (TPN) or Hyperalimentation.
Given by central or peripheral veins.
Subclavian, internal jugular vein used for <4 weeks
If More than 4 weeks: Peripherally inserted central venous catheter.
By peripheral vein, Isotonic or mildly hypertonic solution is given
If hypertonic feed gives - Sclerosis, phlebitis, swelling occurs.
Form of nutrients should be given in TPN
1. Carbohydrates should be given in form of Dextrose
2. Fat should be given in form of emulsified fat
3. Protein should be given in the form of Amino acids.
Carbohydrate : -
- Conc. 5 do 70% of glucose.
- Give 3.4 Kcal/g.
- Provide 60-70% of Calorie needs.
Protein :
- Amino acid given, conc" 3.5 to 20%.
- Give 4 Kcal/g.
Fat Emulsion (Lipids) :
- Provide 30% of Calorie.
- Prepaned from Soyabean, Sunflower & emulsified c̅ egg yolk.
People showing allergy c̅ egg yolk, do not give.
Glucose Intolerant person-Give fat emulsion.
If adverse Reaction of lipid (sign-Chest pain, back pain, Chills, cyanosis, Dyspnoea)
Stop Infusien & then notify the physician.
PN administer within 24 hours after preparation & Refrigerate. Remove from the refrigerator before 1/2 or 1 hour.
Insulin adds c̅ Infusion to control glucose level. Because high glucose is present in PN,
Heparin is added to prevent fibrous clot formation on the catheter tip.
Not discontinue PN abruptly because it may cause hypoglycemia, so I flow rate gradually.
Complication of PN
(1) Air Embolism
Also Complication of IV Infusion
Due to disconnected or open catheter
Air enters during IV tubing changing.
S/S:- Chest pain, dysproca, loud churning sound on auscultation, Rapid weak pulse.
Priority action :
(1) Clamp catheter
(2) Position left side lying c̅ trendelenburg (to trap air in right heart)
(3) Notify physician.
(4) Give O2
For IV tubing & Cap change-Instruct client for valsalva maneuver.
Turn head to the opposite side of I.V. intention It Tse Intrathoracic venous pressure
Take a deep breath, hold & bear down.
(2) Hyperglycemia :
Weakness, kussmaul Respiration, thrist, Polyuria.
Priority :
(1) Notify the physician
(2) Infusion rate (40-60 ml/hr)
(3) Give Insulin.
(3) Refeeding Syndrome :-
In severely malnourished client, c̅ PN rapid drop in K+, magnesium & phosphate
serum level.
(4) Hyperkalemia :
Bounding pulse, crackles, Jugular vein distension, weight gain
Priority :
(1) Slower or Stop IV Infusion,
(2) Restrict fluid
Rapid weight gain indicate abnormality:
(5) Hypoglycemia :
Shakiness, weakness, < 70 mg/dl.
Priority :
(1) Administer IV dextrose (10% )
(2) Notify physician
(6) Infection :
Use strict aseptic technique because PN contains high glucose; medium for bacterial growth.
Monitor temperature & Redness at catheter site.
Priority :
(1) Notify the physician
(2) Remove catheter, tube & send to laboratory for culture of microbes
(3) Take blood culture.
(4) Give Antibiotics
(7) Pneumothorax :
Due to improper catheter placement.
Take chest X-Ray before giving PN.
Priority :- Notify physician.
Intravenous therapy
In haemorrhage & severe hypovolemia administer colloids (plasma expanders)
Eg :- Dextran, Albumin is given, because it Tes Intravascular volume by pulling fluid from Interstitial space.
With I.V. Cannula Infiltration is common.
In a needle catheter ; it can cause catheter embolism.
Catheter Gauze ↑es then diameter Ves.
For emergency fluid administration, administration of blood products & anesthetics, -14, 16, 18, 19 Gauze used.
For peripheral fat infusion-20, 21 gauze.
For standard & clear 1. V. fluid --22, 24 gauze.
For Pt with very small vein - 24, 25 gauze.
IV tubing :- ..
Fluids can't flow unless it is vented.
Macrodrip = 10-20 gtt/mi drop factor =15
Used for adult
Microdrip = 60 gtt/ml, drop factor =60
In a pediatric client.
Filter:- 0.22 um filter
1.2 um-To give lipid & albumin
Change the tubing every 24 to 72 hours.
Nacl (NS) Interchangeable terms. Before giving medicine IV. 1-2 ml NS is used to clean & then give medicine & also flush 1-2 ml NS to maintain patency
IV site selection :
(1) Vein in hand, forearm & antecubital fossa are suitable
(2) In adult => Not use legs & feet vein, because risk of thrombus formation & pooling of drug in
venous return area.
(3) In the Infant Scalp & feet vein.
(4) Use distal site first for Infusion,
(If vein rupture, Infiltration occurs & proximal vein can be used for next puncture)
If antecubital vein Infiltrates, then lower veins of same arm can't be used for punctane.
(5) Avoid taking B.P. on arm receiving I.V. Infusion.
(6) Avoid IV site :
- Edematous extremity.
- Mastectomy side arm.
- Arm that is weak, traumatized, paralysed.
- AV fistula or shunt for dialysis.
- Infected skin area.
(7) In adults the best site is the forearm because bones support it.
Change venipuncture site - every 48 to 72 hours.
Change I V dressing - every day.
Change I V tubing - every 24 to 72 hours.
Administer solution -with in 24 hours, not beyond this period because bacterial growth may occurs in fluid.
Priority Nsg action in Inserting 1.V. line :
(1) Check physician prescription, determine size & type of infusion, explain procedure to patient. (2) Select vein.
(3) Clean skin (Inner to outer circular motion).
Priority for removing IV Line :
(1) Check physician prescription, explain procedure to client, ask to hold arm until needle removal.
(2) Turn off I. V. tubing clamp & remove dressing.
(3) Apply light pressure on site & remove catheter.
(4) Apply pressure for 2-3 minute.
(5) Inspect the site for redness, drainage, swelling.
(6) Document procedure,
A patient of congestive heart failure; Do Not give saline solution - It incrise fluid retention & worsens CHF
Complications of I.V. therapy :
(1) Air Embolism
(2) Catheter embolism :- Occur due to breakage of catheter tip during insertion or removal.
S/S :- B.P., pain in vein, weak & rapid pulse, cyanosis of nail beds, loss of consciousness.
Intervention :
(A) Place a tourniquet proximally of I.V. site.
(B) Notify the physician Immediately.
(C) Circulatory/Fluid overload
Priority :
(a) Slow the infusion rate.
(b) Give an upright position.
S/S :- Coughing, Rapid breathing, dyspnoea, crackles.
(3)Electrolyte Imbalance : -
Place a red medication sticker if KCl is given. Ringer lactate contain K+, so not give to client c̅ renal failure.
(4) Hematoma :
S/S :- Ecchymosis, swelling, painful lump.
Action :- Elevate extremity & Apply pressure & Ice.
(5) Infection
(6) Infiltration (Extravasation) :
S/S :- Edema, pale, coolness at site.
Prevention :-(1) Avoid Venipuncture over the area of Flexion.
Priority :- (1) Remove I.V. device Immediately.
(2) Elevate extremity & apply compress.
Don't rub infiltrate sites, c can cause hematoma.
C/M :- Reddened, warm, painful, edematous proximal to I.V. site Insertion.
(7) Phlebitis :- Inflammation of vein
Priority:-(i) Remove I.V. device Immediately.
(2) Restart in the opposite extremity.
Central Venous Catheter
Catheter position determined by radiography after Insertion
Give trendelenburg or supine position, ask to perform valsalva maneuver to T pressure central vein
Patency is maintained by flushing c̅ heparin. NS Solution
In PICC (Peripherally inserted central catheter) bleeding occurs upto 24 hour, but not after period & phlebitis may occur.
Epidural Catheter-In epidural space
Aspiration before giving medication, if I miele fluid (CSF) or blood returns, notify physicians anesthesiologist immediately, because catheter in subarachnoid space or blood vessel.
Contraindication :
Skeletal or spinal abnormalities.
Bleeding disorders
Use of anticoagulants.
Multiple abscesses & Sepsis.
If any medication added to I.V. bag- Rotate agitate bag gently.
A severe hypotensive & unresponsive client 5% dextrose in RL (Hypertonic Solution) be it draw fluid from cells & Tes Intravascular fluid
Discharge of patient
A permission given to patients to leave the hospital.
MLC :- Medico legal case
ABSCONDED :- Left hospital without Information.
LAMA:- Left Against medical advice.
Leaving the hospital after notifying the staff.
Discharge planning starts at the time of admission.
Patient should be Informed in advance (on the day or previous day) for discharge
. Q.: Responsibility of nurse during discharge
Ans. Health talk
Mercy Killing (Euthnasia)
- Active :- Death by removing assistance devices
- like - Ventilator or O2
- Passive :- Giving lethal dose.
- Eg :- High dose anaesthesia.
Medication
Medicine - Substance used for Desired
- effect/favourable outcome
- Favourable Unfavourable.
- Eg :- PCM
(5) Endotracheal Intubation.
position- Supine c̅ neck extended.
(6) Life Saving drags. :
serum level.
(4) Hyperkalemia :
Bounding pulse, crackles, Jugular vein distension, weight gain
Priority :
(1) Slower or Stop IV Infusion,
(2) Restrict fluid
Rapid weight gain indicate abnormality:
(5) Hypoglycemia :
Shakiness, weakness, < 70 mg/dl.
Priority :
(1) Administer IV dextrose (10% )
(2) Notify physician
(6) Infection :
Use strict aseptic technique because PN contains high glucose; medium for bacterial growth.
Monitor temperature & Redness at catheter site.
Priority :
(1) Notify the physician
(2) Remove catheter, tube & send to laboratory for culture of microbes
(3) Take blood culture.
(4) Give Antibiotics
(7) Pneumothorax :
Due to improper catheter placement.
Take chest X-Ray before giving PN.
Priority :- Notify physician.
Intravenous therapy
In haemorrhage & severe hypovolemia administer colloids (plasma expanders)
Eg :- Dextran, Albumin is given, because it Tes Intravascular volume by pulling fluid from Interstitial space.
With I.V. Cannula Infiltration is common.
In a needle catheter ; it can cause catheter embolism.
Catheter Gauze ↑es then diameter Ves.
For emergency fluid administration, administration of blood products & anesthetics, -14, 16, 18, 19 Gauze used.
For peripheral fat infusion-20, 21 gauze.
For standard & clear 1. V. fluid --22, 24 gauze.
For Pt with very small vein - 24, 25 gauze.
IV tubing :- ..
Fluids can't flow unless it is vented.
Macrodrip = 10-20 gtt/mi drop factor =15
Used for adult
Microdrip = 60 gtt/ml, drop factor =60
In a pediatric client.
Filter:- 0.22 um filter
1.2 um-To give lipid & albumin
Change the tubing every 24 to 72 hours.
Nacl (NS) Interchangeable terms. Before giving medicine IV. 1-2 ml NS is used to clean & then give medicine & also flush 1-2 ml NS to maintain patency
IV site selection :
(1) Vein in hand, forearm & antecubital fossa are suitable
(2) In adult => Not use legs & feet vein, because risk of thrombus formation & pooling of drug in
venous return area.
(3) In the Infant Scalp & feet vein.
(4) Use distal site first for Infusion,
(If vein rupture, Infiltration occurs & proximal vein can be used for next puncture)
If antecubital vein Infiltrates, then lower veins of same arm can't be used for punctane.
(5) Avoid taking B.P. on arm receiving I.V. Infusion.
(6) Avoid IV site :
- Edematous extremity.
- Mastectomy side arm.
- Arm that is weak, traumatized, paralysed.
- AV fistula or shunt for dialysis.
- Infected skin area.
(7) In adults the best site is the forearm because bones support it.
Change venipuncture site - every 48 to 72 hours.
Change I V dressing - every day.
Change I V tubing - every 24 to 72 hours.
Administer solution -with in 24 hours, not beyond this period because bacterial growth may occurs in fluid.
Priority Nsg action in Inserting 1.V. line :
(1) Check physician prescription, determine size & type of infusion, explain procedure to patient. (2) Select vein.
(3) Clean skin (Inner to outer circular motion).
Priority for removing IV Line :
(1) Check physician prescription, explain procedure to client, ask to hold arm until needle removal.
(2) Turn off I. V. tubing clamp & remove dressing.
(3) Apply light pressure on site & remove catheter.
(4) Apply pressure for 2-3 minute.
(5) Inspect the site for redness, drainage, swelling.
(6) Document procedure,
A patient of congestive heart failure; Do Not give saline solution - It incrise fluid retention & worsens CHF
Complications of I.V. therapy :
(1) Air Embolism
(2) Catheter embolism :- Occur due to breakage of catheter tip during insertion or removal.
S/S :- B.P., pain in vein, weak & rapid pulse, cyanosis of nail beds, loss of consciousness.
(A) Place a tourniquet proximally of I.V. site.
(B) Notify the physician Immediately.
(C) Circulatory/Fluid overload
Priority :
(a) Slow the infusion rate.
(b) Give an upright position.
S/S :- Coughing, Rapid breathing, dyspnoea, crackles.
(3)Electrolyte Imbalance : -
Place a red medication sticker if KCl is given. Ringer lactate contain K+, so not give to client c̅ renal failure.
(4) Hematoma :
S/S :- Ecchymosis, swelling, painful lump.
Action :- Elevate extremity & Apply pressure & Ice.
(5) Infection
(6) Infiltration (Extravasation) :
S/S :- Edema, pale, coolness at site.
Prevention :-(1) Avoid Venipuncture over the area of Flexion.
Priority :- (1) Remove I.V. device Immediately.
(2) Elevate extremity & apply compress.
Don't rub infiltrate sites, c can cause hematoma.
C/M :- Reddened, warm, painful, edematous proximal to I.V. site Insertion.
(7) Phlebitis :- Inflammation of vein
Priority:-(i) Remove I.V. device Immediately.
(2) Restart in the opposite extremity.
Central Venous Catheter
Catheter position determined by radiography after Insertion
Give trendelenburg or supine position, ask to perform valsalva maneuver to T pressure central vein
Patency is maintained by flushing c̅ heparin. NS Solution
In PICC (Peripherally inserted central catheter) bleeding occurs upto 24 hour, but not after period & phlebitis may occur.
Epidural Catheter-In epidural space
Aspiration before giving medication, if I miele fluid (CSF) or blood returns, notify physicians anesthesiologist immediately, because catheter in subarachnoid space or blood vessel.
Contraindication :
Skeletal or spinal abnormalities.
Bleeding disorders
Use of anticoagulants.
Multiple abscesses & Sepsis.
If any medication added to I.V. bag- Rotate agitate bag gently.
A severe hypotensive & unresponsive client 5% dextrose in RL (Hypertonic Solution) be it draw fluid from cells & Tes Intravascular fluid
Drug
- Substance that alter the normal functioning.
- ex.-Heroine, cocaine, caffeine.
All medicines are drugs but not all drugs are medicine.
Categories of Drugs
Astringent→ Contraction of tissue & arrest discharge
Analgesic → Pain relief
Antipyretic→ Fever ↓se
Antipruritic → To prevent Itching
Antitussive →Cough Suppressant ( ↓se)- Cough
Antiemetic →Suppress Vomiting
Inotropes → Cardiac contractility ↑se.
Chronotropic →Increase Heart Rate
Mydriatics→ Pupil dilation - fundus Exam. of eye.(i.e.Atropine)
Miotic→ Pupil constriction (Pilocarpine)
Antifungal → Prevent growth of fungus.
Antihypertensive→ ↓B.P.
Purgative→ Constipation release, increases peristalsis.
Cathartics→ To ↑es evacuation of bowel
Anthelmintics→ Against parasites
Antiseptic →Prevent growth of pathogens
Antibacterial→ Bacteria Killing (Antibiotics)
Diuretics→ ↑es urine output
Antacids →Neutralise HCL
Emollients→ Smoothening of fecal matter
Lanotropics→ Candiac contraction
Sedatives →To relieve anxiety (relaxation)
Antipsychotics→ Against Schizophrenia (Mental Illness treatment)
Antianxiety → To relieve anxiety.
Antimani →To relieve manic psychosis.
Bronchodilator→ Dilater bronchioles.
Antispasmodics→ To ↓se spasmodic pain/spasm
Sialagogue ↑se saliva secretion
Gastric tonic/ ↑se tone, function, appetite of Stomach
Hydrogogues →Produce copious watery
Cholagogues→ ↑es bile secretion
Caustics →Substance destructive to living tissue
Diaphoretics→ ↑es sweating
Demulcents →Soften, soothe & protect mucus memb.
Emmenagogues →Stimulate menstrual discharge
Stypics →Agent checks haemorrhage
Vesicants→ Blistering agent
Antidote →Counteract the drugs/poisión
Synergistics →Affect total outcome due to 2 combined drugs
Important symbols :
O.D→ Once a day
B.D → Twice a day.
T.D.S. → Thrice a day
Q6H → 4h time a day. (Every 6 hourly)
Stat → At once (Immediate)
P.r.n. → When required
S.O.S. → Emergency
H.S. → At night
A.C. → Before meal
P.C. → After meal
H → Hour
Q → Every
A.M→ Before noon
P.M → After noon
Att die→ Alternate days
O.N. → Each night
T.O → Telephonic orde
Rx→ Prescription.
С.М. → Tomorrow morning
Rep. → Repeat
Q.: Which drug should not be given h.s. = Diuretics.
Q.: Maximum absorption of drugs occurs if given.
Ans. A.C. (Before meal).
If a drug causes gastric Irritation (so give P.C.).
Q.: A drug is prescribed as Q4H How many doses Will the nurse give to the patient ?
Ans. 6
Measurements
1CC = 1ml
1 Dram = 4gram
= 4ml (cc)
= 1 teaspoonful
= 60 grain song
1 ounce = 30 gm
= 8 teaspoonful
= 480 grain
= 8 dram
= 30ml (cc)
1 Litre = 1000 ml
= 400 Ounces
= 2pint (1 PINT = 500 ML)
= 1 quart
1 Gram = 15 grain
Infusion Time =Total Volume to be infused / ML IN hour infused
1 kg = 2.2 lbs (pound) = 1000 gm.
1 Tablespoon = 4 dram= 15 ml= 3 tsf
1 glassful = 200ml
1 teaspoonful = 4-5ml
1 ml = 60drops.(Pediatric)
1 ml=15 drops(adult)
1 grain (gr) = 60-65 mg.
cup = 30ml
1/50grain = 0.4 mg
1 pint - 500ml
1 Kg - 2.2 lbs Medicine
1 lbs - 480 gm.
1 glass -- 200 ml.
1 Teaspoon 4-5 ml
1 Tablespoon = 15 ml (3 teaspoon).
1 Insulin Syringe = 1 ml (40 unit).
1 foot = 12” (30 cm).
Calculation
Drug, Doses & fluid :
1. Fluid (Drop/min) - Total Volume(ml)xDrop factor divaid byTime in min.
Diop Factor = gtt (Drop) ÷ min. = 60 ÷ 60= 1 gtt/min
Drop factor -60(For paediatric)
Drop factor = 15
Q.: A pt. is Infused 2 pint of DNS in 3 hours, calculate the drop/min
Ans.= 1000x15 ÷ 8x60 = 31.25
Murphy set :- Paediatric drip set.
Murphy sign :- Gallbladder disease (+ve sign) Palpation, Cessation of deep inspiration.
Q.: Administer 200 ml N.S. in 10 hours in a 3 month old baby
Ans. 200x60 ÷ 10x60 = 20Drop/min.
NS = 0.9%, Isotonic fluid.
Categories of Fluid available in Hospitals
Calculation of Drug doses in children
Hypotonic = N.S. (0.45%)
NOTE-
- Hartman Sign :-Small amount bleeding at implantation time.
- Hartmann's Solution :- RL
- Hartman's Pouch :- Gallbladder
- Hartmann's Procedure :- End Colostomy
Formulas used in calculation
(1) Young's formula :- (1 to 12 year of children).
ChildDose=Age of Child In Years x Adult Dose divaid byAge(years) +12
(2) If child is < 1 year of age (Fried's formula)
= Age of Childin month x Adult Dose divaid by 150
(3) Clark's formula - (on basis of weight)
Child Dose= Wt.in pond x Adult Dose divaid by 150
(4) On basis of body surface area
B.S.A= Kg/M2
Q:You have to prepare 1% molar solution 200 ml, from 5% solution, calculate the amount.
Ans. =- 100 x 200 ÷5
= What we want x quantity ÷What we have
= 40ml polar, 160ml water.
Q: Calculate the doses of tablet pcm for a 2 year old child
2 x 500÷2+12 = 71mg. PCM
Q: Calculate the doses of the tab. PCM for a child weighing 4 Kg.
Ans. = 8.8x500÷1500=29.3mg.
Q.: 400 ml of N.S. is to be infused in 2 hours, calculate drops.
Ans. 400÷2 x 15÷60 =50drop/min.
Q.: 3 Its normal saline is Infused in a day to 5 year old child, whose body weight is 13 Kg. Calculate drops/Minute.
Ans. = 3000x60÷24x60 =125drop/min.
Q.: Gentanıycin 2 ml = 80 mg., administer 20mg in a child of 2% age.
Ans. 0.5ml.
Q.: HIV +ve patient's blood spills on floor, clean by which technique ?
=By 1% Sodium hypochlorite,
= Firstly reduce diameter :- By tissue paper / gauze
For Absorb
↓
(15-20 min) Na-hypochlorite...
↓
Clean By gloved hand
↓
discard gauze in Yellow bag
Routes of medication
1. Oral route
Most common route - Oral (Enteral)
2. Intramuscular route
I.M. - Intramuscular - 90°
Doses :- 3ml
Muscle site-Deltoid (T.T.)
Gluteal
Vastus lateralis (In child)
Side effect :- Irritation of tissue (sc)
Z-track technique :- To prevent Irritation or Inflammation of subcutaneous tissue.
Z-track technique :- Stretch skin, puncture needle site & leave the skin,
Purpose :- To prevent medication comes back in subcutaneous tissue.
↓
To prevent Inflammation & Irritation.
Drugs:
Dextran, discardgauze, Iron Injections
Don't massage site
Remove needle after 10sec.
Vaccine :
(a) I.M. Route: -DPT, T.T , D.T, Hepatitis B.
Pentavalent :-DPT, Hib., Hep.B.
(b) Sub-cutanceous or Hypo-dermal
Angle of needle insertion: 45° .
(1) Measles Vaccine, MMR Vaccine => 9 month
(2) Insulin
(3) Erythropoietin Inj.
(4) Heparin
(c) Intradermal :- 15°
(1) BCG Vaccine - For T.B.
(2) Drug Sensitivity test - Mantoux test (PPD Doses 0.1ml)
Purified protein derivative
Leukemia -> 5 mm (HIV pt. T.B. +ve)
Lab. worker > 10 mm (In Contact with others)
> 15mm (not in contact then T.B. +ve).
= Reading (48-72 hours).
(d ) Intra osseous :- In Bone.
(e ) Intra thecal/Intra spinal :- Spinal cord.
(f) Topical :- On body surface.
(g) Instillation :- In body orifice, In liquid form
(h) Insertion :- In body orifice In Solid from
(i) Insufflation :- In body orifice, In Powder from
(j) Induction :- Apply on Skin 7 friction.
HOT & COLD Applications
Principle :
Conduction
Convection
Evaporation
Radiation
Hot application
Vasodilation -↑ peripheral circulation. -Muscular Relaxation -Promote healing
Contraindication :- In Kidney pt.
- In Neuro pt.
- In heart pt
- In acute Inflammatory Condition, hot application is strictly prohibited.
- In acute appendicitis don't use Hot application (B'coz it can rupture )
- In tooth abscess
Cold application
Vasoconstriction- ↓ Peripheral circulation
Used to prevent necrosis, because it decreases demand of tissues
To put dead body at freezing point to prevent pathogen growth & to prevent degeneration ofTissue.
Contraindication :
- In shock & Collapse
- In edema.
- Impaired circulation
- D.M., Arteriosclerosis,
- In shivering pt.
- In muscle spasm
Hot Application
- Dry
- Moist
1. Dry heat application: = 120° - 149°F
- Short wave diathermy :- Sunlight
- Hot water bottle
- Lamp & bulb.
- Radiation
- Electric Cradle heating pads.
- Phototherapy
- Blankets
- Aquathermia pad
Note :- Dry hot application temperature is always more than moist hot application temperature B-coz dry appliances does not comes in direct contact to body
Moist - may cause burning at high temp.
Moist heat application
Moist hot application temperature = 110 - 1150F
General-Bathing
Local -Hot compression (Fomentation)
(1) Simple fomentation :- Woolen cloth (not cotton cloth)
(2) Medicated :- Stupes, Poultices (Turpentine)
(3) Paraffin bath :-(In arthritis patient) :- To ↓es pain
15-30ml Mineral oil adds 1 pound of paraffin wax.
To decrease stiffness of joint
(4) Sitz bath-Temperature :- 110-115°F.
- Solution used :- KmnO4,(1:5,000,- Boric acid (may used) (1 dram to 1 pint) Eusol solution.
Indication :-
- Hemorrhoids
- Episiotomy :- First 24 hours apply ice packs
- Dysmenorrhoea
- Perineal surgery
Hot water bottle :- Not fill full (fill only 3/4)
- Temp = 120° - 149°F (48.80-65°C)
- Provide Hot water bottle to the patient with urination problem (not passing urine)
- Rationale - Because It relaxes muscles.
- Another method :- Open tap water.
Q.: A patient is on antibiotic therapy for longer duration which vitamin deficiency?
Ans. Vit K :- Bcoz prolonged antibiotic therapy Kill normal flora essential for vit K synthesis.
Q.: Ideal duration of hot application.
20-40 minute (20minute-In sitz bath.)
Interval = 1 hour
Secondary effect produces when duration more & Interval less
Like - Vasoconstriction
Secondary effects are Just opposite effect to primary.
Cold Application :-Duration=20-40 minute, Interval=1 hour
Secondary effect = Vasodilation.
1. dry
- Ice cap
- Ice collar
- Ice packs
- Ice cradle
- Ice Leg
- Chemical (Cold pack)
Moist
- Cold Sponging -(65-90°F)
- Cold bath
- Cold blankets
- Tepid Sponging-(85° - 100°F)
Elimination- Stool
- Urine
- Stool -Problems related to fecal elimination :
- Constipation
- Obstipation
- Fecal Impaction-(Due to pancreatic juice, the stool becomes sticky).
Methods to relieve the problems :
1. Suppositories
2. Enema (Clysis)
3. Enteroclysis (Colonic Irrigation)
Fluid requirement = 2-3 Lt
Enema
1. Evacuated (18”) hight 45 cm
Fluid amount: 250-1000 ml 100-120ml
Temperature of fluid: 105-110 F
100°F (Children)
2. Retained enema -hight 18-20cm ,98.6F
Fluid amount: 100-120ml
Insertion of tube-3-4" (Adult) 1-1/2" (Child)
Position: Left lateral position
Advice to take deep breath during the procedure (Panting breathing)
Types :
Simple - (Soap + H20 enema)
- -500-1000ml (Adult)
- -250-500ml (Child)
- < 250 ml(infant)
Clod enema-In hyperpyrexia
Medicated enema are
1. Oil enema
- Used oil: Olive oil
2. Purgative enema/cathartic
Purpose: To 1 peristalsis
To releive constipation
→ It cause irritant mucosa
3. Carminativel antispasmodic enema
Purpose :- To relieve flatulence/Tympanites.
Use : - Turpentine
4. Astringent enema
Purpose: - To relieve Inflammation (Colitis) of colon
Crohn's disease :- Intestinals Inflammation.
Cohn's disease :- Hyperaldosteronism, Nat & H2O retention BP ↑se.
5. Anthelmintic
Exercises :
Q.: A patient is suffering from Tympanites what kind of enema a nurse should give?
Ans. Carminative enema.
Q.: Position of evacuated enema
Ans. Left lateral, Due to anatomical structure. [with gravity] of sigmoid colon remains at lower level of anus in left lateral postion.
Retained enema :- Fluid retain in body.- Height :- 18-20cm
- Amount of fluid: 100-120ml
- Temp :- Equal to body temp.
- Slow Administration by murphy drip set
Answer the following questions
Q.: The liquid used for fogging. (O.T. Sterilize)
. Ans. Echo sheild.
Q: For defecation, position should be?
Ans. Squatting position.
Q: Cyanotic spells of TOF pt ,Nurse action?
Ans. Knee chest position. = O2, Administration.(Priority)
Q.: Dose of PPD
Ans. = 0.1ml, ID.
= Purified protein derivative
= Mountouxe test for T.B.
=> 5mm (HIV, Leukemia)
Q.: Route of measles - Subcutaneous (0.5ml).
Ans. 9 Month.
Q.: Why Z technique Use for I.M. Inj?
Ans. To prevent backflow of drug in SC tissue & prevent Irritation of tissue.
Q.: Osmotic pressure of plasma is bcoz of
Ans. Albumin protein
Q.: Catheterization of female pt. position.
Ans. Dorsal recumbent.
Q.: Temp of sitz bath - 110-115°F.
Q.: Duration of Tepid sponging - 20-40 minute.
Q.: Phagocytes of bone - Osteoclast
Q.: Shape of hepatocytes => Hexagonal.
Q.: Green colour of sputum- Bronchiectasis
Q.: White colour stool - Barium dye Inject.
Q.: White Milky urine :- Chyluria - Filariasis
Q.: Complication of hyperemesis - Metabolic Alkalosis.
Q.: Step Ladder pattern of fever - Typhoid.
Q: Pyridoxine (Vit B) is a drug that is used to minimise [peripheral neuritis] Complication of Isoniazid.
Stages of Death
There are 5 stages of death
1. Denial - Refuse.
2. Anger
3. Bargaining - Compromising with the cause with real condition.
4. Depression
5. Acceptance
Last sense to disappear in dying person is helly
Clinical sign of death => Fixed dilated pupil, Not responding to reflex.
Stiffening of muscles Firstly from Jaw. Rigor mortis :- Rigidness of body. (Disappear after 5-6 hours.)
If the dead body is stored placed in deep freezing.
Rational-Pathogens growth not occur, so to prevent autolysis of body
Live body in deep freezing -To ↓se metabolism & 02 requirement
Sample from dead body => Autopsy.
Pastoral Care :- To meet the spiritual need
Q: If the body is HIV +ve how body packing is done?
Ans. Pack the body in plastic bag Grey
Radial pulses first disappear in death.
Q.: Orifices of body plug Cotton ball, Why?
Ans. To prevent body discharge from coming outside.
Q.: The role of a nurse with caregivers of dying patient is
Empathetic - Involved in the situation completely.
Sympathetic - Accept Feeling, but self control,Leader, Motivator
Q.: For oral hygiene of a client a nurse is needed.
Ans. 1 Teaspoon of NaCl & 1/2 pint of water the quantity taken by nurse
(1) 5mg NaCl + 500ml water 1 pint
Q.: Dysentery = Blood & mucus present with Diarrhoea.
Ans. Left lateral
Q.: The application of Ice bag for fever patient is based on
Ans. Conduction
Q.: Secondary effect of coid App.
Ans. Vasodilation.
Q.: Painful micturition = Dysuria.
Abnormal cell size = Dystrophy.
Dysphasia - Speech difficulty
Dysphagia :- Swallowing difficulty
Dysmenorrhoea :- Painful M.C.
Dysrhythmia :- Abnormal rhythm of heart
Discharge :- Give permission to pt. to leave hospital
Sinus Rhythm :- Normal rhythm
Glycosuria - Presence of sugar in urine.
Benedict test (Glucose oxidase test).
incrise specific gravity of urine.
Rothera's test = Ketone in urine.
(Na Nitroprusside).
Smith test = Bile pigment.
Hey's test- Bile salt.
Sputum sample = 15ml.
Blood sample = 3-5ml.
Q.: 12 May 1820 - Birth Horace Night angle.
Ans. 13 Aug 1910 - Death. In Italy.
Q.: A System of family centered care to a dying patient - Hospice care.
(1) Palliative :- To relieve signs & symptoms.
(4) Rehabilitative:- Restoration of optimal functioning.
Foot rest :- To prevent foot drop.
Invasion of microorganism/pathogen in a host - Infection.
Duration of HCAI is -- 48hour.
Q.: Destruction of all pathogenic organisms
Ans. Disinfection.
Q.: Destruction of all kinds of pathogens
. Ans. Sterilization.
Q.: Asepsis - Freedom from pathogens.
Q.: Sepsis - Infection.
Q.: Bacteriostatic - Stop growth of transmitting
disease. (microorganism)
Q; Separation of an Infected person from non an infected person, is called Isolation
Ans. Quarantine. → Upto Incubation period of a disease, a person is put under custody/observation.
Disinfection
Isolation
Sterilization.
Q.: Isolation room press. - Negative pressure.
Q.: The natural power of body to with stand the toxins or the organism of a disease.
Ans. Immunity - Resistance of body.
Q.: Autoclaving - 121°C temp,15lb- pressure, 15-20 min - Duration.
Q.: Total cessation of breathing - Apnoea.
Q.: Chenye stroke respiration. Ans. Polypnoea with pause. Tachypnoea. Rate & Rhythm increse.
Hypoxia – lack of O2 in tissue.
Hypoxemia - lack of O2 in blood.
Q.: Anorexia - loss of appetite
. Q.: 1 ounce - 25 gm, 30ml.
Q.: I.M. - 90°. - Vastus lateralis (In child)
Blood transfusion
- Test :- ABO/Rh.
- Bag strength: 450ml
Test for :- HIV/Hepatitis/Syphilis (VDRL)
- After removal from freeze, adininister within 30min.
- After removal wait for 15min.
- Administration complete within 4 hours to preven Infection
- Transfusion of clotting factor - Cryoprecipitate
- FFP - Plasma
- Platelet
- Packed RBC.
- Whole blood - Slowly administer. WBC.
- Check vitals just after administration & monitor pt for 30 minutes.
- Rx" sign - Dyspnoea, chest pain, Iteching, Redness Shock
- Glucose & Rb. (Dextrose) - taking before B.T., then not use this, always prefer new I.V. line.
Normal Value
Heamoglobin :-at birth 18gm%
Adult male — 14-16gm%
Adult female — 12-14gm%
RBC/erythrocyte :-4.5-6.5 million/mm2 of blood
TLC:-WBC/Leukocyte :- 4-11000/mm3 of blood
Platelet Thrombocyte :- 1.5-3.5 lac/mm2 of blood
DLC :-
- Neutrophiles - 40-70%
- Eosinophiles -1-6% -7 konum
- Basophiles-0-1% Lymphocyte - 20-40%
- Monocyte - 2-10%
PCV (Packed Cell Volume) -
- Male - 38-55%
- Female - 35-45%
ESR (Erythrocyte sedimentation rate) :
- Male - 0-15 mm/1st hours
- Female - 0-20 mm
B.T. :- 2-7 minute
C.T. :- 4-9 minute
P.T. (Prothrombin time):- 9-11 Second
BUN :- 15-45 gm/dl
Total bilirubin :
- Conjugated - 0-0.3 mg/dl
- unConjugated - 0.1-1 mg/dl
Uric Acid :-2.5-8 mg/dl
Total protein :- 5.5-8 mg/dl
Administration of blood products
Autologous donation :- Donation of client's own blood before procedure.
Blood Salvage :- Autologous donation that inyo suctioning blood from body cavities, joint sp,
Compatibility :- Matching of blood.
1. Fresh frozen plasma :- To † clotting factor lever blood or for volume expansion
2. Packed RBC transfusion :- To replace RBC
1 unit is Infused b/w 2 & 4 hours.
1 unit les 1g/dl Hb. & hematocrit by 2%to 3%
Washed RBC (depleted in plasma, platelet & history of a leukocytes) prescribe for patient c̅ allergic transfusion
3. Platelet :
To treat thrombocytopenia.
Infused rapidly after taking from blood bank, within 15-30 minute
4. Fresh frozen plasma :
Change of frozen solid to liquid by gradual warming
Infused c̅ in 2 hours
Rh & ABO compatibility is required,
Effectiveness is determined by clotting studies, prothrombin time, partial thromboplastin time, Universal donor => O - ve
Universal Recipient = AB+ve
5. Cryoprecipitates :
Prepared from fresh frozen plasma, stored for 1 year.
1 unit administered in 15-30 minute.
Used to replace clotting factors, specially factor VIII & fibrinogen.
6. WBC :- Administer in sepsis & neutropenic patient.
1unit : 400 ml; give in 1 hour.
Nursing consideration while transfusing
If a large volume of blood, infused rapidly via a central venous catheter; it can cause cardiac dysrhythmia.
No solution other than NS is added
Never add medication into blood transfusion.
Nurses should assess vital sign & lung sound before transfusion
Take Informed consent before transfusion.
If temperature clevated, before beginning transfusion notify physician,
18-19 gauze needle is required for maximum flow rate of blood products
Storage of blood is usually 35 days.
Acetaminophen & Diphenhydramine is given if history of adverse Reaction.
Stay c̅ client for first 15 minute to notice any
transfusion Rx".
Sign of Immediate transfusion Rx"_
• Chills & diaphoresis.
• Ache
Rashes, hives, itching, swelling.
Sign of Rx"in unconscious client
Weak pulse, hypotension, fever, brady & tachycardia
Oliguria & Anuria, Visible hemoglobinuria.
Delayed transfusion Rx":-Days to years after.
Fever, mild jaundice, ved hematocrit level.
• Iron overload.
Priority Action in patient c transfusion Reaction :
(1) Stop transfusion Immediately.
(2) Change I V tubing down to I.V. site & Keep
I.V. line open 7 Ns. (0.9%)
(3) Stay c̅ client & check vital signs (Every 5 min.)
(4) Give emergency medication.
Antihistamine, Corticosteroids.
(5) Take urine sample.
(6) Return the blood bag, tubing to the blood bank.
Iron overload :
Due to repeated transfusion in anemia & thrombocytopenia.
S/S :-Diarrhoea, Vomiting, hypotension.
T/t :- Give Deferoxamine (IV & SC) to remove accumulated Iron..
Urine turn red after giving this drug, duc to Iron excretion
Diseases because of blood transfusion -
1. Hepatitis C, transmits most commonly by transfusion
S/S :- Anorexia, nausea, vomiting, dark urine, jaundice.
Occurs within 4-6 week after transfusion. Others :- Hep. B, HIV, herpes , Ebstein-Barr
Virus, malaria etc.
2. Hypocalcemia -
Occurs when citrate transfuses in blood, it blinds c̅ ca+ & excreted.
S/S :- Hyperactive reflex, paresthesia, tetany, muscle cramp, +ve trousseau's sign & + ve
chvostek's sign.
Action :-(1) Slow transfusion & notify physician.
3. Hyperkalemia :
Stored blood liberate K+ through hemolysis.
So give fresh blood to the client to prevent risk of hyperkalemia.
S/S :- Paresthesia, weakness, abdominal cramp, diarrhoea, dysrhythmia
Action :- Slow transfusion & notify physician.
CSF:- Normal Finding
Cell Count :- Erythrocyte :- Ab.
WBC/Leukocyte - 0.2/mm2
Sugar (Glucose) - 50-80 mg/dl
Chlorides - 700-760 mg/dl
Protein contain - 15-45 mg/dl
Clotting Factor
I. Fibrinogen Factor
II. Prothrombin Factor
III. Thrombin Factor
IV. Calcium Factor
V. Labile Factor
VI. Sno blood clotting Factor
VII. Stable Factor
VIII. Antihemophilic Factor-A
IX. Christmas/Antihemophilic Factor-B
X. Stuart Factor
XI. Plasma tissue thromboplastin/Antihemophilic Factor
XII. Hagmar Factor
XIII. Fibrin stabilizing Factor
Albright syndrome :- Abnormal development of bone and excessive pigmentation of skin
Apert's syndrome :- Congenital disorder of webbing of finger.
Marble size stool :- Irritable bowel syndrome
FIT:- . (Fecal immunochemical test/occult blood detection):- Test use for detection the HB percent in stool
→ Use for colon cancer
NG Tube length :- 76 cm
Neso intestine tube :- 120 cm Length
Size :- 8-12 French
Bernstein test :- Test use for GERD
Endotracheal Tube Placement :- T4-T5 (Just above carena)
TIPS (Transjugular intrahepatic portosystemic shunt)
:- Shunt use in Hepatic cirrhosis
Laennec's cirrhosis :- cirrhosis due to alcohol
Drug of choice in myasthenia gravis :- Neostigmine bromide
Temperature increase after delivery :-100.4°F Normal up to 24 hrs.-Relege dehydration effect of baby
Tape test - Pinworm
Acetaminophen (thylone) :
Antidots + N-Acetylcysteine (mucomyst)
Erythrocyte protoporphyrin test :- test to detect leadpoision
Decreased perception.
Increased blood pressure but susceptibility to postural hypotension
Respiratory rate usually remains unchanged.
Increased constipation tendency & dehydration.
Loss of hearing ability :- Low pitched tones are heard more easily.
Long term memory not disturbed.
Decreased GFR
Confusion is a common sign of infection in older adults, especially Infection in the urinary tract.
Acute change in Mental status in older clients is a common sign of adurese Rx" Reaction to medication. (Mostly in UTI)
Individual who are at more risk for abuse include those are dependent booz of their immobility or altered mental status
Any suicide threat from on older client should be taken seriously.
ABHR :- Primary mode of hand hygiene in 24 health case setting
Change-vere puncture site in 72-96 hours.
I.V. tubing 72 hour
Don't let an IV beg or bottle of solutions hang for more than 24 hours to diminish for potential for bacterial contamination & possibly sepsis.
Before adding medication to the solution, swabs access ports with 70% alcohol and equally alternative solutions.
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