~SEMINAR QUESTIONS~

COMMUNITY HEALTH
1. (a) Define housing
(b) Outline the components of an ideal home.
(c)What factors are responsible for poor housing in the community?
(d)Explain the harmful effects of improper housing.

2. (a) Define the term occupation health.

(b)Outline the common occupational hazards in a hospital setting.
(c) Explain how occupational hazards can be prevented.

3. (a)Outline the causes of malnutrition in the community.

(b)What is a role of nurse/midwife in prevention of community malnutrition?

4. (a) Define community mobilization.

(b)Describe how you would mobilize a community towards implementation of a health education
program.

5.(a) There is a problem of typhoid in the community, prepare a health education talk to address
this problem.
(b) What challenges would you anticipate during preparation of your talk?

6. (a) What is an epidemic?

(b) Describe how you would manage an epidemic in the community.

7. (a) What is the importance of the school health programme?

(b) Outline the components of a school health programme.
(c) What is a role of a nurse in the provision of a school health services?

8. (a) What is CBHC?

(b) Explain the importance of CBHC programmed in the community.
(c)What is a relationship between PHC and CBHC?

9.a) What is community emergency?

b) Outline the community emergencies you know.
c) How would you manage community members after a landslide?
(KABALE SCHOOL OF NURSING AND MIDWIFERY

10. a) Define PHC

b) Explain the concept of PHC.

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c) How has PHC been missed in your community?
d) Differentiate between PHC and CBHC.
(SALEM BROTHER HOOD SCHOOL OF NURSING AND MIDWIFERY)

11.a) Outline the structure and functions of the spermatic cord.

b) Describe the secretion that passes in the spermatic cord.
KULUVA SCHOOL OF NURSING

12.a) Explain the types of water diseases and their examples.

b) Explain the ways of purifying water in;
i. Small scale
ii. Large scale
TUMU SCHOOL OF NURSING AND MIDWIFERY

13.a) Describe the pelvic floor.

b) What are the signs and symptoms of septic abortion?
c) Describe the management of a mother with septic abortion both in health center and hospital.
KAMULI SCHOOL OF NURSING AND MIDWIFERY

14.a) Describe the pelvic floor

b) With the aid of a well labeled diagram, describe the pelvic floor muscles
c) State the functions of the pelvic floor
VICTORIA UNIVERSITY

15.a) Describe the physiological changes which take place during labour
b) What is pregnancy?
c) Outline the characteristics of normal pregnancy
d) What changes occur in reproductive system during pregnancy?
(NGORA SCHOOL OF NURSING AND MIDWIFERY)

16. A prime gravid was brought to health center with history of labour for three days while at
home. She looks exhausted on abdominal examination, a bundle ring is seen.
i. What is your diagnosis of the mother?
ii. Outline the signs and symptoms of the above condition.
iii. What will be the management of this mother in the health center and the hospital?
iv. Give five nursing diagnosis for the condition
v. List the complications of the above condition.
(KAGANDO SCHOOL OF NURSING AND MIDWIFERY)

17.A new born baby of five days has been admitted with jaundice.
i. What may be the cause of that condition?
ii. What will be the management of this baby?

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 iii. How can neonatal jaundice be prevented?
iv. What complications may follow this condition?
(LACOR SCHOOL OF NURSING AND MIDWIFERY)

18.a) Define PHC

b) Explain the concept of PHC.
c) How has PHC been missed in your community?
d) Differentiate between PHC and CBHC.
(SALEM BROTHER HOOD SCHOOL OF NURSING AND MIDWIFERY)

19. a) What is drug addiction?

b) How would you assess and assist the patient recover from drug addiction?
(FLORENCE NIGHTNGALE SCHOOL OF NURSING)

20. a) With a well labeled diagram describe fetal blood circulation.

b) What are the changes that occur at birth?
c) Give the functions of fetal circulation (KALONGO SCHOOL OF NURSING AND MIDWIFERY)

21. a) Define OHS, hazards, risky hazards control and hazard complications
b) List the aims of occupational health.
c) List 15 good safety or health practices you would apply at your health facility to safe guard
staff.
d) Outline four methods would use to identify hazards at your work place.
(KIU WESTERN CAMPUS)

22. a) Define 3rd stage labor

b) Outline the physiology of 3rd stage labor
c) How would you manage a mother who starts bleeding as soon as the placenta is expelled?
(VIRIKA SCHOOL OF NURSING AND MIDWIFERY)

PEDIATRICS
23. (a)Define the term immunization.
(b)Explain the immunization schedule in Uganda according to UNEPI.
(c)Explain how you can improve routine immunization services in your community to avoid vaccine
preventative diseases.
(JINJA INTERNATIONAL INSTITUTE OF HEALTH SCIENCES)

24. A 4 weeks old neonate is admitted on ward with history of fast breathing chest in drawing
and stridor
i. What would be your appropriate diagnosis for this neonate?

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 ii. Explain the specific nursing care you would offer to this neonate in a hospital setup in the
eight hours.
iii. Mention any differential diagnosis for this condition.
(GULU SCHOOL OF NURSING AND MIDWIFERY)

25. a) With aid of a well labeled diagram, illustrate important internal structures of the fetal
skull.
b) Discuss how you would prevent cerebral injuries in the new born baby.
c) State the complications of cerebral injuries.(JINJA SCHOOL OF PAEDIATRIC NURSING)

26. a) Define the term neonatal tetanus and name the causative agent.
b) Name the route of entry.
c) Give the signs and symptoms of neonatal tetanus.
d) Which management will you give to a child suffering from neonatal tetanus?
(LIRA SCHOOL OF NURSING AND MIDWIFERY)

27. (a) Explain the term isoimmunisation

(b) Discuss how a RR- mother with a RH+ father can be managed for their blood incompatibility
to save their off springs
(FORTPORTAL INTERNATIONAL SCHOOL OF NURSING)

28. (a) Discuss the developmental milestones of a three year old toddler.
(b) Explain factors that affect growth and development in infancy period.
(KAROLI LWANGA SCHOOL OF NURSING AND MIDWIFERY)

29. (a) Define malnutrition.

(b) Explain how a 3 year old toddler with severe acute malnutrition and can be managed in
stabilization phase.
(c) Mention the possible complications this toddler is likely to get.
(ISHAKA ADVENTIST SCHOOL OF NURSING AND MIDWIFERY

30. (a) List 10 abnormalities of pregnancy.

(b) What are the causes of fundal height bigger than weeks of amenorrhea?
(c) How would you diagnose multiple pregnancies?
d) Outline specific complications of pregnancy and labour.
(HOIMA SCHOOL OF NURSING AND MIDWIFERY)

31. (a) what are the characteristics of normal labour?

(b) Outline the signs and symptoms of obstructed labour.
(c) Describe the management of obstructed labour in health centers.
(d) Give specific complications of obstructed labour.
(MUTOLERE SCHOOL OF NURSING AND MIDWIFERY)

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32. a)Define obstetrical emergency.
b) List 10 obstetrical emergencies.
c) Give signs and symptoms of impending eclampsia.
d) Describe the management of a mother admitted in hospital with eclampsia in the first 48 hours.
(KAMPALA UNIVERSITY SCHOOL OF HEALTH SCIENCES)

33. a)Define puerperal pyrexia.

b) List causes of puerperal pyrexia.
c) Outline management of a mother who reports with puerperal sepsis in birth health center and
hospital.
d) List the complications of puerperal sepsis.
(KISIZI SCHOOL OF NURSING AND MIDWIFERY)

34. Outline the causes of post-partum hemorrhage.

Describe management of a mother who starts bleeding soon after delivery of a baby in health
center.
MAYANJA MEMORIAL SCHOOL OF NURSING

35. Define caesarian section.

List down the indications of caesarian section.
Outline the management of a mother for effective caesarian section from admission to discharge.
(ALICE ANUME SCHOOL OF NURSING AND MIDWIFERY)

36. a) What is fetal distress?

b) Give the causes of fetal distress.
c) Describe the management of fetal distress in hospital.
d) How can you prevent this condition?
(LIRA UCI SCHOOL OF NURSING)

37. a) Define anemia.

b) What are the causes of anemia in pregnancy?
c) Describe the management of a mother admitted in hospital with severe anemia in pregnancy.
d) How can you prevent anemia during antenatal period.
(NYENGA SCHOOL OF NURSING AND MIDWIFERY)

38. a) Define acute inversion of the uterus.

b) What are the causes of the above condition?
c) What is the immediate management of this condition in hospital?
d) Mention complications of acute inversion of the uterus.
(S.T KIZITO HOSPITAL MATANY SCHOOL OF NURSING AND MIDWIFERY)

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39. a) Define cord prolapsed.
b) What are the causes of this condition?
c) Outline principles of managing cord prolapsed.
(NTUNGAMO SCHOOL OF NURSING AND MIDWIFERY)

40. a) Explain the stages of rigor.

b) Describe the management of mother with severe malaria in pregnancy while in hospital.
c) List of complications of malaria in pregnancy.
(BUSOGA UNIVERSITY SCHOOL OF NURSING AND MIDWIFERY)

41. a) What is breech presentation?

b) How can you differentiate well flexed breath from an extended breech?
c) Outline maneuvers used in management of breech presentation.
d) List complications of breech delivery.
ANNE NEHEMA MEMORIAL INSTITUTE OF HEALTH SCIENCES (MARACHA DISTRICT)

42. a) Outline physiological changes of pregnancy that can complicate cardiac disease.
b) Outline complications of precipitate labour.
c) Write all you know about placenta aecreta?
(KYAMBOGO SCHOOL OF PUBLIC NURSES COLLEGE)

GYNAECOLOGY SECTION
43. a) Define abortion.
b) Define the different types of abortion.
c) What is the management of a lady who reports to hospital with inculpable abortion?
GOOD SAMARITAN SCHOOL OF NURSING

44.a) Draw a diagram of a uterus indicating sites of fibroids.

b) Differentiate between benign and malignant tumor.
c) Give the management of the mother after myomectomy within the first 48 hours
d) What is specific advice would you give this mother on discharge?
ARUA SCHOOL OF NURSING AND MIDWIFERY

45.a) Define the term vaginal fistula.

b) Outline the causes of vaginal fistula.
c) Using the nursing process, give the management of a woman after repair of vesico vaginal
fistula. (IGANGA SCHOOL OF NURSING AND MIDWIFERY)

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 SURGERY QUESTIONS
46. A thirty year old lady has sustained severe burns of the abdomen?
a) Describe his management up to 72hours.
b) Explain the complications of burns.
IUIU MBALE SCHOOL OF NURSING AND MIDWIFERY

47.a) Define thyrotoxicosis.

b) Outline the clinical features of thyrotoxicosis.
c) Differentiate between hyperthyroidism and hypothyroidism.
KIBULI SCHOOL OF NURSING AND MIDWIFERY

48. Samuel a 30 year old peasant has been presented to OPD with all the features of tetanus.
a) Describe his management from admission up to discharge
b) Outline the clinical features of tetanus.
MENGO SCHOOL OF NURSING AND MIDWIFERY

49.a) A seventy year old man is admitted on surgical ward with acute retention of urine.
b) Outline the signs and symptoms of benign prostate hypertrophy.
c) Describe the post-operative nursing care following prostatectomy up to discharge.
d) Explain 7 complications following prostatectomy.
NSAMBYA SCHOOL OF NURSING AND MIDWIFERY

50. a) What is blood transfusion?

b) Describe five complications that may occur due to blood transfusion.
c) What would cause failure of a blood drip to run during blood transfusion?
d) Explain the nurse‟s responsibility before, during and after blood transfusion.
(KALUNGI SCHOOL OF NURSING)

51. Mr. Kakembo has been diagnosed with peritonitis in OPD Lubaga hospital.
a) Define peritonitis.
b) Outline the causes of peritonitis.
c) Mention the signs and symptoms of peritonitis.
(RWENZORI SCHOOL OF NURSING AND MIDWIFERY)

52. A twenty five year old year lady has been diagnosed with intestinal obstruction.
a) Mention the causes of intestinal obstruction.
b) Describe the pre and postoperative management up to discharge.
(AGULE SCHOOL OF NURSING AND MIDWIFERY)

53. a) Define a wound.

b) With examples classify wounds.

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c) Explain the process of wound healing.
d) Mention 5 common complications wound.(ST. ELIZA SCHOOL OF NURSING AND MIDWIFERY)

54. Joseph a thirty three year old lady has been presented to OPD with all the features of
osteomyelitis.
a) Define osteomyelitis.
b) Outline the clinical features of osteomyelitis.
c) Describe the management of Joseph up to discharge.
(MBALE SCHOOL OF NURSING AND MIDWIFERY)

55. a) Define hernia.

b) State the different types of hernia.
c) List complications of inguinal hernia.
d) Describe the preoperative care of a patient with hyperglycemia.
(SOROTI SCHOOL OF COMPREHENSIVE NURSING)

MEDICINE SECTION
56. A four year old child is diagnosed with measles and need your care.
a) What are the five functions of the skin.
b) List the ten signs and symptoms of measles.
c) What nursing care will you give child for the first 72 hours?
d) Mention five complications of measles.
LUBAGA HOSPITAL TRAINING SCHOOL

57. Mrs Ketty 22 year old lady has been admitted to your ward with severe asthma.
a) List 7 signs and symptoms of broncho asthma.
b) What management will give to a patient admitted with severe asthma from admission until
discharge?
c) What five complications are likely to occur to this patient?
(BWINDI SCHOOL OF NURSING AND MIDWIFERY)

58. There is a lot of peptic ulcer in most of the people around you.
a) Outline five predisposing factors of peptic ulcers you know of.
b) List 7 signs and symptoms of peptic ulcer.
c) What management will you give to a patient with peptic ulcers from admission until
discharge?
(JERUSALEM SCHOOL OF NURSING AND MIDWIFERY)

59. a) What 7 factors can cause /make a pulse change?

b) What nursing care will give to a patient with hypertension from admission until discharge?
c) List three complications of hypertension.

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(RAKAI SCHOOL OF NURSING AND MIDWIFERY)

60. a) With aid of a well labeled diagram describe the cross section of the kidney.
b) Outline the stages of renal failure.
c) Describe the management of a female adult with acute renal failure
d) What are the causes of renal failure?
(MASAKA SCHOOL OF COMPREHENSIVE NURSING)

61. You have received a patient at OPD with severe anaemia

a) What are erythrocytes?
b) Mention ten signs and symptoms of anaemia
c) What management will you give this patient from the time of admission until discharge?
MULAGO SCHOOL OF NURSING AND MIDWIFERY

62. It has been identified that many people have had stroke due to many causes.
a) What are the three major causes of stroke?
b) Mention five different diagnoses of cardio vascular accident.
c) Describe the nursing care you will give to a person who has sustained stroke with paraplegia
from admission until discharge.
SOROTI SCHOOL OF COMPREHENSIVE NURSING

63. Mr. Ogwang is admitted to a medical ward with acute cholecystitis as a provisional diagnosis.
With the aid of a well labeled diagram describe bile formation.
Explain the different types of jaundice.
Explain the management of Mr. Ogwang‟s condition until discharge.
List possible complications of cholecystitis.
(JINJA SCHOOL OF NURSING AND MIDWIFERY)

64. a) With the aid of a well labeled diagram describe the blood circulation through the heart.
b) Name the blood groups and describe how each group donates and receives blood.
c) State the functions of blood. (VILLA MARIA SCHOOL OF NURSING)

65. A patient is brought to your ward unconscious with a medical condition.

a) List ten possible medical causes of unconsciousness.
b) In details while using neurological chart explain how you will manage this patient
c) What five complications is this patient likely to get?
KIWOKO SCHOOL OF NURSING AND MIDWIFERY

66.a) Describe the cycle of respiration.

b) List 7 predisposing factors of tuberculosis.
c) In details what health education will you give to a patient admitted for the first time with
tuberculosis?JINJA SCHOOL OF NURSING AND MIDWIFERY

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67.a) Define the term malaria.
b) List 4 species of plasmodium.
c) Describe the management of Mr. Okello who was admitted with severe malaria until discharge.
d) Outline the immediate and intermediate complications of malaria.
e) Describe the life cycle of malaria in man.
(RUGARAMA TRAINING SCHOOL KABALE)

68.a) Define the term diabetes.

b) Differentiate between inspidus and diabetes mellitus.
c) Mention specific investigations of a patient suspected to be presenting with diabetes mellitus
and signs and symptoms.
d) Describe the management of a 35year old patient with hyperglycemia.
(MULAGO SCHOOL OF NURSING AND MIDWIFERY

OBSTETRICAL ANATOMY/NORMAL MIDWIFERY

69. a) Define the first stage of labour.
b)What are the characteristics of normal labour?
c) How would you admit a mother who comes in active labour?
d) Outline management of a mother during first labour.
ARUA SCHOOL OF COMPREHENSIVE NURSING

70.A gravid 3 Para 2 comes with a history of amenorrhea from 3 – 5 months, severe abdominal
pain and bleeding
i. What is the diagnosis?
ii. With a well labeled diagram describe the site where it normally occurs
iii. What are the signs and symptoms?
iv. What are possible outcomes?AGA KHAN UNIVERSITY

71. a) What is integration of RH services?

b) What are the reasons for integrating RH?
c) What are the benefits of integrating RH to a client and service provider?
d) What are the rights of a client?
MENGO SCHOOL OF NURSING AND MIDWIFERY

72 .Mother comes to the maternity center having been infected with HIV/AIDS
i. What method are you going to use to allay her anxiety?
ii. What are the qualities of a good counselor?
iii. What are the steps of counseling?
iv. What are the principles of counseling?IBANDA SCHOOL OF NURSING

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73. Maternal mortality is a great problem in Uganda.
i. What is the definition?
ii. What is the percentage?
iii. What are the causes?
iv. What can the government do in order to reduce maternal mortality?
LUGAZI SCHOOL OF NURSING AND MIDWIFERY

PSYCHIATRIC SECTION
74. Mr. A.K Living in the white house, being presented with the following signs and symptoms;
picking rubbish and eating them, hearing his voices being broadcasted over BBC radio station,
hearing two voices discussing and commenting about him and having unkempt body hygiene.
a) What would be your likely psychiatric diagnosis? Support your diagnosis.
b) What other clinical presentations would Mr. A.K present with?
c) Make five Nursing diagnoses for Mr. A.K.
d) How would you manage Mr. A.K up to the time of discharge?
BUTABIKA SCHOOL OF PSYCHIATRIC NURSING

75. Define community mental health Nursing?

b) Explain the importance of community mental health Nursing.
c) Explain the roles and responsibilities of a mental health Nurse in a community?
d) How would you prepare for the resettlement of a mental patient who had a chronic mental
illness?
BUTABIKA SCHOOL OF PSYCHIATRIC NURSING

PHARMACOLOGY SECTION
76. Cate aged 38 years was diagnosed with rheumatoid arthritis by the rheumatologist in a
private clinic. He prescribed Indomethacin 50mg 8 hourly to be taken after a meal. After two
weeks of continuous use of the medicine, Cate developed heart burn which she associated with the
intake of the medicine.
a) Define rheumatoid arthritis.
b) Outline the criteria used to diagnose rheumatoid arthritis in primary care.
c) Explain the pharmacology of the drugs used in the treatment of rheumatoid arthritis
including the nursing implications.
BISHOP STEWARD SCHOOL OF NURSING AND MIDWIFERY

77. Write short notes on the following drugs.

a) Ergometrine

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 b) Oxytocin
c) Misoprostol- KIBALE SCHOOL OF NURSING AND MIDWIFERY

78. a) Define post-traumatic stress disorder?

b). discuss the clinical manifestations of a 23 years old female with a history of rape.
c). Describe the psychological, social, medical and nursing care for this lady.
d) What are the criteria of diagnosing the above condition?
e) State at least three nursing diagnosis that is likely to be presented by this lady.

79. a) Briefly explain the pharmacology of typical antipsychotics.

b) Outline how the side effects associated with typical antipsychotics can be manage.

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 ~SOLUTIONS TO THE QUESTIONS~
COMMUNITY HEALTH
Question 1
a) Define housing
b) Outline the components of an ideal home
c) What factors are responsible for poor housing in the community?
d) Explain the harmful effects of improper housing.
Solution

a) Housing: Is a structure in which we live, work, rest or play

b) Components of an ideal home include;

 Physical structure of a house(main house should be built on the firm ground with enough
space in outside and well ventilated, strong walls and roofing).
 The kitchen well ventilated with a chimney for smoke outlet.
 Latrine and a bathroom about 30m away from the main house.
 Animal house.
 A spacious compound which is clear
 A food store
 A proper water drainage
 Arrear by water source or water harvesting tanks

c) Factors for poor housing in our communities, these include the following;

 Overcrowding  Natural disasters

 Poverty  Lack of land ownership fear of theft
 Traditions etc
 Ignorance  Immigrations
 Political instability
d) Harmful effects of improper housing include the following;

 Spread of infection e.g. respiratory disease due to overcrowding.

 Skin disorders e.g. scabies and louse infestations
 Diarrheal diseases due to lack of safe water and proper sanitation
 Jigger infestation
 Poor living conditions which may result in psychosocial problems such as alcoholism, drug
abuse, promiscuity, delinquency and school drop outs
 General ill health resulting in constant morbidity and stunting growth

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Question 2
a)Define the term occupation health
b) Outline the common occupational hazards in a hospital setting.
c) Explain how occupational hazards can be prevented.
Solution

a)Occupational health is also defined as the physical, mental and social wellbeing of man in
relation to his work and working environment, his adjustment to work and the adjustment of work
to man (Forsman 1976)

b) Occupational hazards common in hospital setting;

Physical hazards

 Radiation x-rays  Slips and falls and trips

 Electrical shocks  Lighting (too little or too much)
 Needle stick injuries
Chemical hazards

Contact with chemicals such as drugs, detergents, anaesthetic agents, latex allergy and mercury.

Psycho-social hazards

 Abusive patients
 Long working hours
 Work place violence
 Sexual harassment from bosses and fellow workers

Biological hazards

 Blood borne pathogens (HIV, HBV, HCV)

 Air borne diseases

c) Prevention of these hazards

Primary prevention

 Health education aiming at personal life styles and use of protective gears.
 Assessment for fitness for work by carrying initial medical examination prior to starting
work (pre-employment medical screening).
 Promotion of wellness activities at work programs.
 Environment monitoring including air monitoring to reduce health risks in case of hazardous
substances are involved.
 Establishing and implementing health and safety at work regulations

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  Sensitization of new workers on the operations of their job and risks of using equipment
involved.
 Sensitize workers and their employers on their obligations as stipulated in the occupational
safety and Health Act, 2006, the labour law.
 Employers to provide safety gears such as gloves, aprons, eye gurgles, ear muffs,
overalls, gum boots, and fire safety apparatus.

Secondary Prevention

 Health surveillance and health screening: e.g. blood pressure, cholesterol level, lung
function and other chronic diseases.
 Treatment including efficient first aid management, early ambulation for quick access to
the health services.
 Health counselling by providing individual support on ill health issues.
 Emergency preparedness for example ambulances, fire fighting equipment and mobile
evacuation team and properly trained first aid staff must be on a standby at work place
all the time.

Tertiary prevention

 Rehabilitation and settlement of those disabled by occupational injuries

 To ensure that the victims are compensated appropriately in accordance with labour laws
e.g. worker‟s compensation act of 2000, occupational safety and health act, employment
act, arbitration and resettlement act and trade union act (2006)

Question 3
a) Outline the causes of malnutrition in the community
b) What is a role of nurse/midwife in prevention of community malnutrition?
Solution

(a) Definition of malnutrition

Malnutrition is a disparity between the amount of food and other nutrients that the body needs
and the amount that is receiving. This imbalance can result into under nutrition or over nutrition

Causes of malnutrition in the community

 Age: basal metabolic rate (BMR) and physical energy expenditure vary with age e.g.
kwashiorkor is common in children
 Sex: pregnant mothers usually suffer from nutritional anemia
 Habits and traditional beliefs: e.g. the habit of taking fast foods rather than taking
traditional foods
 Social economic factors e.g. people will less income suffer more from under nutrition whole
the rich suffer more from over nutrition

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  Physical factors e.g. climate, geographic location home effects on nutrition
 Population density: over populated areas compete for resources including food and more
likely to suffer from nutrition
 Prevalence of communicable and parasite infestation e.g. measles in children and
intestinal worms
 Unfavorable climate conditions e.g. Droughts
 Life styles e.g. Consuming a lot of alcohol (alcoholism) and smoking can cause malnutrition
 Political instability
 Natural disasters etc

(b) The role of a nurse in prevention of malnutrition in the community

 Health education on harmful life styles
 Advocating for poverty alleviation program and surplus for sale
 Encourage or provision of micro nutrient supplementation e.g. irons for girls and vitamin A
for children.
 Prevention of infectious diseases such measles, malaria and diarrheal through immunization
and proper sanitation.
 Improvement of the status of women through adult history programmes
 Advocating for land reforms to reduce the vulnerability of landless.
 Carry out nutritional sensitization and education focusing on infant feeding of other special
groups.
 School going children, pregnant women and lactating mothers
 Advocating for nutritional programs and monitoring then functionality
 Carry out nutritional surveillance.
 Early identification of malnutrition and referral for rehabilitation
 Treatment of diseases e.g. measles and diarrheal diseases.

Question 4
a). Define community mobilization.
b). Describe how you would mobilize a community towards implementation of a health
education program.
Solution

a) Community mobilization

This a process of bringing people together for desired propose as individuals or groups to plan,
implement and eradicate activities in order to achieve a desired goals.

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b). How would you mobilize a community?

Preparing to mobilize (pre – entry phase)

 Gather information about and review its profile.

 Plan for resources to be used during mobilization

Initial community contact phase

 Contact community leaders (gate keepers)

 Create a good relationship with them
 Share with then your objectives

Problem identification phase

 With help of community leaders perform community assessment.

 Carry out field survey and collect information, analyze and identify community.
 Organize meeting with the community leaders and give them a feedback.

Prioritizing health problems

 Create awareness about the health problems in the community through a community
meeting and prioritizing the identified problems according to the magnitude and severity.

Interventional planning

 Identify resourceful persons and other resources needed to solve the problem

Implementation (action phase)

 Take the problems in order of their priorities.

 Involve community members to actively participate in implementation.

Sustainability phase:

 Ensure that once the project had started will continue even in absence of external support.
 Set up committee to oversee the continuity of the project.

Participatory evaluation

 Involve the community and local leaders in evaluation to find out what was done and what
was/is left undone.

Re-planning: should be done basing in evaluation report, identify lessons learnt. It is aimed at
improving the out of the planned and implementated project.

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Question 5
a) There is a problem of typhoid in the community, prepare a health education talk to address
this problem?
b) What challenges would you anticipate during preparation of your talk?
Solution

a) Prepare a health education talk about prevention of typhoid in the community.

Format of writing a health talk

TOPIC: DATE:
GROUP: TIME:
OBJECTIVES: [Use action verbs]
1. 2.
TEACHING AIDS: For example a chart showing...............
TEACHING METHODS [Use any of the teaching methods below]

 Discussion
 Roles plays
 Demonstration
a) INTRODUCTION
Should include:- greeting, names and purpose and where you came from;
1. Topic of the day
2. Objectives expected to be covered- this may be optional.
b) ASSESS LEARNERS PRIOR KNOWLEDGE
1. Write questions to ask the group in relation to the objectives of the topic.
c) BODY
2. Start with definitions if possible
3. Cover all the objectives
4. Use simple language i.e. avoid medical terms
5. Emphasize the key points
6. Use teaching aids appropriately
d) GIVE the group a chance to ask questions and better use the group to answer first.
e) ASK questions to evaluate the talk, to see if they have learnt.
f) Summarize the key points.
Assign on how to use the knowledge and close by thanking the group
b) Challenges that may be anticipated during preparation

 Inadequate resources such teaching  Physical disabilities; e.g. Poor sight

materials. and hearing.
 Hostility and uncooperative  Health status of the participants.
participants.  Rumours and misconception about the
topic.

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  Dressing code  Lack of learning material
 Weather conditions; for example  Suitability of meeting place
rainy season.  Time management
 Failure to control the class  Poor mobilization

Question 6
a) What is an epidemic?
b). Describe how you would manage an epidemic in the community.
Solution

a) Definition of the term Epidemic.

This is an outbreak or the occurrence of a disease clearly in excess of normal expectation in a

given area for a specific period of time.

b) Management of Cholera epidemic in a community.

Epidemic management activities include taking appropriate control measures, such as treating
those who are ill to reduce the reservoir of infection, and providing health education to limit the
transmission of the disease to others.

Case management:

 Patients are admitted in a temporary facility e.g. school, tents (cholera camp) in the
community for example; in case of cholera.
 Consideration of appropriate laboratory investigation will also assist in narrowing down
the list of possible differential diagnoses and arriving at the right diagnosis.
 Patients are managed with water and electrolyte replacement in case of dehydration and
electrolyte depletion...
 Treat the cause with appropriate antimicrobials e.g.; cotrimoxazole, erythromycin,
ciprofloxacin and doxycycline.

Disease prevention and control measures:

 Body fluids such as vomitus and stool should be properly disinfected and disposed of.
 Water purification: All water used for drinking, washing, or cooking should be sterilized
by boiling or chlorination in the area where cholera may be present.
 Food safety: Avoid uncooked food Left overs should be kept covered to prevent
contamination by flies. Food vendors must be stopped until the epidemic is controlled.
 Chemoprophylaxis for immediate contacts e.g. Cotrimoxazole is also used to treat case
contact as a prophylaxis in case of cholera.
 Markets and other public institutions must be inspected

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Health education to the community/ public
 Washing of cooking and eating utensils using soap and hot water, dry them on a rack and
store them in a cabinet and out of the reach of children and animals such as dogs, cats
and chickens.
 Conduct hygiene education for the general public and especially for food handlers of
mass catering institutions such as prisons, restaurants and hospitals.
 Sanitation should be improved
 Proper use of pit latrines
 Hand washing

Disease Surveillance:-

 This is continuous watching of all aspects of disease, field investigations such as culturing. It
describes the magnitude and distribution of diseases by place, time and personal
characteristics such as age and sex.

 Public health surveillance of communicable diseases involves continuous data collection,

examination of the data (data analysis), interpretation of the data, and dissemination of
the information to concerned bodies such as the District Health Office and the nearby
Health Centre. Disease Surveillance will help to evaluate progress towards the control
measures

Question 7
a) What is the importance of the school health programme?
b) Outline the components of a school health programme.
c) What is a role of a nurse in the provision of a school health services?
Solution

a) Definition of school health programme

Definition; School health programme is community health program that refers to all school
activities that contribute to understanding, maintenance and improvement of the health of pupils/
students and school personnel.

Importance of school health programme

 Strengthen health education: - this creates awareness and improves the behaviour change
among school children, staffs, PTAs, and school management.
 Ensures good sanitation in schools e.g. having adequate and clean latrines, classrooms,
dormitories and compounds, proper facilities for hand washing and disposal of sanitary
towels.
 Promotes provision of medical, eye and dental care to school children, staffs, as well as
periodic deworming and TT immunization for girls under reproductive age.
 Helps to promote better nutrition and feeding practices in school.
 Promotes proper use and maintenance of water source supply

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  Promotes conducive psychosocial environment in school by reinforcing rules/policies among
children and staff to reduce ill health practices e.g. smoking, alcoholism, drug abuse, and
sexual practices among students.
 Provides counselling services and adolescent health services in school.

b) Components of school health programme

Health teaching and health education on various health issues such as;
 Personal hygiene
 Food hygiene
 Environmental sanitation
 Prevention of HIV/AIDS and STIs
 Prevention of communicable diseases
 Growing up
Nutrition- Provision of nutritional supplements or midday meals to school children.
Immunization - Protection of all school-going children against preventable diseases by
immunization. This includes also mass deworming for school children.
Maintenance of healthful school environment by:
 Water supply and safe drinking water
 Sanitation e.g. provision adequate Latrine, Urinals and composite pit or refuse baskets.
 Ventilation- present for good light and fresh air
 Playground- for recreation and physical education.
Training of teachers to enable them to be involved in the school health programme.
School health screening examination- Regular physical examination from the head- to – toe (see
the details below).
Curative services such as Treatment and early referral.
 Special problem for example provision of dental and eye care services.
Rehabilitative care for handicapped children with both physical and mental disability.
School health inspection (to observe whether the school environment is safe and conducive to
children).

c) The role of a nurse in provision of school health services

N.B The role of a nurse is either to provide the above services or advocate for some of them.

Question 8
a) What is CBHC?
b) Explain the importance of CBHC programmed in the community.
c) What is a relationship between PHC and CBHC?
d) What is Community Based Health Care?
Solution
a) Definition of community based care
Community Based Health Care is a community programme on health and care, in which the
community is actively involved in identifying their problems and needs, prioritizing them and
mobilizingtheir own resources to meet those needs.

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b) Importance of CBHC programme
 It addresses all aspects of health care - preventive, promotive, curative, rehabilitative,
and palliative- at community level.
 CBHC increases people‟s sense of control over issues that affect their lives; people‟s
willingness to identify problems and felt needs and to find solutions.
 It encourages community fully participation in dealing with appropriate activities required
to solve the health problems of the community.
 It empowers the communities to plan within the available resources, implement and
evaluate their activities.
 There is a feeling of ownership, self-reliance, confidence and self-esteem of community
members.
 CBHC encourages unity, strength, and a spirit of solidarity amongst community members.
 By participating in development projects, community members can promote equity by
ensuring those with the greatest need and the greatest risk have their needs prioritized.
 The CBHC programme is usually comprehensive and integrated, involving health,
agriculture, and economic activities by individuals, families and groups within the
community.
c) The relationship between CBHC and PHC
 CBHC is a strategy for achieving the goals of PHC and as an integral part of PHC; it
reinforces the PHC concepts and principles.
 Both CBHC and PHC share the principle of community participation where the community
members are involved in planning within the available resources, implements and evaluate
what has been done.
 The activities of CBHC and PHC programmes are usually comprehensive and integrated
(i.e. addresses all aspects of health care - preventive, promotive, curative, rehabilitative,
and palliative- at community level.
 Both PHC and CBHC programmes involve other sectors like, agriculture, water, community
development and other economic activities at individual, family and group levels within the
community.
 Both PHC and CHBC programmes respond to the needs of the people guided by the
principle of equity and social justice.
 Implementators of PHC and CBHC programmes start with the people in identifying their
needs and works with them in finding solutions.
 Both PHC and CBHC leads to self-reliance. They aim to bring about health reliant
communities where people become armed with knowledge so they depend less outsiders
i.e. reduce on dependency the government and donors.
 Both PHC and CHBC programmes give the communities asense of ownership and
belonging in the health care system. i.e. Community becomes responsible to care for their
own health problems.

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  Both PHC and CHBC programmes empower the community to take systematic care of their
health using available means at affordable costs.

Question 9
a) Define OHS, hazards, risky hazards, control and hazard complications
b) List the aims of occupational health
c) List 15 good safety or health practices you would apply at your health facility to safe
guard staffs
d) Outline four methods would use to identify hazards at your work place

Solutions:
a)Definitions

OHS: This is the promotion and maintenance of highest degree of physical, mental and social
wellbeing of workers through elimination and control of hazardous factors and conditions at
workplace. According to WHO and ILO

Hazards: These are sources of potential damage, harm or adverse health effects on workers and
their health under certain conditions and factors at work.

Risky hazards: These are sources with high chances or probability to cause potential damage,
harm or adverse health effects to a worker.

Control: These are measures or guidelines necessary to protect workers and their health from
exposure to hazardous conditions and factors at workplace.

Hazard complications: These are harmful health effects or health problems on workers and their
health due to exposure to hazardous conditions and factors at work.

b) The aims of OHS include;

– To prevent occupational diseases and injuries.

– To maintain and promote optimal health of the workers.
– To prevent and control occupational hazards.
– To reduce sick absenteeism.
– To achieve maximum human and machine efficiency.
The following are the good safety and health practices necessary to safe guard the staff against
hazardous conditions and factors in a health facility;

 Pre-employment health examination of the staff to rule out any underlying chronic illness
like epilepsy, Hypertension, Sick cell disease.
 Regular general inspection of the working environment of the health facility including
wards, latrines, kitchen etc. in order to identify hazardous factors and conditions.

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  Periodic monitoring and screening of the staff at higher risk of infection and health
problems like staff in TB ward, X-ray units etc. promoting early detection and treatment of
diseases of the affected staff.
 Proper documentation and record keeping pertaining hazardous factors, conditions,
frequent accidents and injuries which is important in formulating preventive and control.
Measures in the workplace

 Routine immunisation of the staff against high infectious diseases like hepatitis B, Yellow
fever, Tetanus etc.
 Preparation and training of the employees on emergency response for incidents like fire
outbreaks, accidental needle pricks.
 Proper hand washing before and after every nursing procedure. This safety and health
practice is very effective by 80% in prevention of most infection in a health facility.
 Proper use of personal protective gears like the gloves, masks, gumboots etc. This is very
important in protecting the staff from direct contact to risky hazards like contagious body
fluids, stool, etc.
 Proper decontamination and sterilisation of the equipment and instruments before and
after use is an important practice in prevention of risky infections like HIV, Tetanus, Sepsis
etc, both to the staff and the patient.
 Developing a proper work schedule i.e. job rotation and work rest schedules which reduce
the contact time of the staff with the hazards, thus important in prevention of stress,
fatigue and other chronic conditions like hypertension and depression related to work
overload.
 Orientation and training of the staff about operating procedures and measures necessary
at the work place, thus preventing the staff from the risky of exposure to hazards.
 Routine maintenance of the equipment in order to keep them in a proper working
conditions. This safety practice reduces the risk of accidental hazards in a workplace.
 Developing and implementing standard operating procedures and measures related to
high risky hazardous units like operating theatres, sterilising rooms and the X-ray units in
the health facility.
 Proper segregation and management of wastes like the use of the safety pin box for
sharp instruments and the red bin for highly infectious wastes, thus preventing accidental
infections like HIV/AIDS, Hepatitis B etc.
 Promotion of general hygiene of the facility including ward cleaning, bed making, dump
dusting and etc. on daily basis to reduce the risk of infection to the staff and the clients.
The main methods used in identification of hazards in a workplace;

 Informal and formal observation programmes. This involves observing work every day
and it‟s extremely important in identifying hazards at the work place.
 Comprehensive workplace survey. This method takes the advantage of the staff
awareness of the presence of hazards in the working environment.
 Individual interviews. This method is most important in uncovering hazardous conditions,
unsafe work practices and their route causes.

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  Review of documentations and report. It involves the review of safety committee minutes
and accidental reports important in determining the common hazard and their rout causes
in the workplace.
 Inspection of the work place. This method is very important in locating hazardous
conditions and factors in the work place.
Question 10

a) Define community emergency.

b) Explain all the community emergencies you know.
c) How would you manage community members after experiencing landslide.

Solutions

a) Community emergency is a calamity which leads to massive destruction of people‟s life

and property and cannot be managed using local resources.
b) The common community emergencies are;
 Manmade ie fire , transport accidents eg road traffic accident, electric shocks, wars, etc.
 Naturally occurring community emergencies i.e.
 Lightening  Famine
 Floods  Landslides
 Thunder storm
 Medical related community emergencies i.e. outbreak of diseases like typhoid, Ebola,
Marburg hepatitis, sleeping sickness, etc.
 Pests & infestation ie banana wilt jiggers, locusts, etc.

c) The management of landslide is in three phase;

RESPONSE PHASE

 In this phase, you are required to act as a leader and collaborate with the leaders
available right from the LC1.
 Assess for number of injuries caused, the area covered by the landslide and population
affected by the landslide. Be able top explain to the responders and cooperate with them
effectively.
 Help identify staging areas that is secure and able to accommodate the population.

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  Recognize the potential hazards associated with the landslide.
 Give first aid to the injured people as necessary.

SAFETY & SECURITY PHASE

 Ensure safet5y of the injured people and get support from the able ones.
 Help to identify, organize and utilize local resources in rescuing people who have
survived.
 Include the able ones in cleaning the homestead.
 Make barriers to prevent and restrict people from going to dangerous places that may
cause more harm like naked electric wires.

RECOVERY PHASE

 Identify needs according to the damage document and communicate to local authorities,
charity organizations e.g. Redcross, churches that may wish to help.
 Psychotherapy is important to people with emotional distress associated with landslides ie
anxiety and post-traumatic stress.

Question 11

a) What is drug addiction?

b) How would you assess and assist the patient recover from drug addiction?

SOLUTIONS
1. Definitions
a) A drug is any substance when taken into the body alters the body‟s functioning at molecular
level.
Addiction is a situation of regular and long use of a drug leading to drug dependence.
Drug dependence is a situation where one cannot stay without a drug that he/she is addicted to.
Drug addiction is an overwhelming compulsion to get the drug by any means available with
psychological and physical dependence leading to withdrawal symptoms when the drug is stop.
b.) Assessment of drug addicts.
Aims of assessment

- To treat any emergency problem.eg withdrawal symptom.

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 - To confirm whether the patient is taking drug basing on history, examination and drug
testing
- To assess the degree of dependency
- To identify social problem i.e. occupational and domestic problem
- To identify physical and mental health problem.
- To assess risky behaviors like; suicidal tendency.
- To determine expectation of treatment and desire to change.
Clinical assessment

- History taking
- Drug testing
- Physical assessment
- Psychological assessment.
1. HISTORY TAKING

 Types of drug used.

 Quantify frequency and pattern of use
 Route of administration
 Symptom of dependence and addiction
 Source of drug including preparation
 Prescribed medication
 Substance use e.g. Tobacco, marijuana etc.
 Alcohol used e.g. Quantity ,Frequency and pattern of use
 Psychiatric history and any current symptoms.
2. LAB INVESTIGATION (DRUG ANALYTICAL TEST)

a.) Screening test

It is usually the first test carried out, it‟s quick, cheap and easy. Done in the lab using a dipstick
tests, here negative results can be reliably accepted while positive need confirmatory test.
b.) Chromatographic tests.
This is a confirmatory test by chromatography and masses of spectrometry where the drugs and
their metabolites can be detected.
c.) Urine testing.
Usually performed and can show drugs used in recent days and is a non – invasive test. Urine
specimen may be adulterated.
d.) Oral fluid testing.
In this oral fluids are easier to collect but drugs are present in lower concentrations and only very
recent drugs use over the last 24 – 48hrs can be detected.

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e.) Hair testing.
This can show drugs used over the past few months, its poor at detecting very recent use.
However, it does not differentiate between continual and sporadic use.
3. PHYSICAL EXAMINATION (ASSESSMENT)
These includes general observation

 Odour of drugs on breath and clothing

 Poor nutritional status
 Poor personal hygiene
b.)On the skin

 Signs of physical injury, bruises, laceration, needle mark

 Loss of hair, rushes, puffy hands
c.) On the head

 Burns of the oral cavity if a smoker

 Inflamed nasal mucosa
 Gum diseases e.g. Gingivitis.
d.) GIT

 On percussion, there is tenderness of epigastric region

e.) Cardiovascular system

 There will be heart murmurs, respiratory sound, tachycardia, and hypertension.

f.) Respiratory system

 Respiratory depression
 Cough, wheezing races
g.) Reproductive system

 Pelvic tenderness and virginal discharge in female

 Testicular atrophy and gyneocomatia in male
h.) Immune system

 Lymphadenopathy
4.) MENTAL STATUS EXAMINATION (ASSESSMENT)
These starts from observing patient‟s behavior during history taking and physical examination.

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a) Appearance, attitude and behavior
- General description.
- Behavior and psychomotor activity.
- Attitude towards examiner.
b) Speech
- Relevant or irrelevant speech.
- Coherent or incoherent speech.
c) Mood (affect) and emotional state
- Subjective feeling
- The interviewer‟s observation
- Appropriateness
d) Thought process and content
- Production of thought
- Continuity of thought
- Content of thought e.g. suicidal ideation Homicidal ideation, delusion.
-
e) Perception
- Illusion
- Hallucination
f) Insight – awareness of addiction
g) Cognitive function
- Orientation
- Attention
- Memory
- Concentration
- Intelligence
h) Personality characteristics
- Reserved (Introvert)
- Social (extrovert)
- Suspicious (paranoid)
- Perfectionist(obsessive)
- Hysterical
- Aggressive
- Antisocial
i) Defence mechanism
ASSISTING THE PATIENT TO RECOVER FROM DRUG ADDICTION
Treatment and recovery approaches must be aimed at addressing each patient‟s drug use
pattern and drug related, medical, psychiatric and social problems
Principles of recovery

- Treatment of withdrawal symptoms

- Stabilizing or staying in treatment
- Rehabilitation or extended care programme

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1. TREATMENT OF WITHDRAWAL SYMPTOMS
When patient first stop using drugs they experience a variety of physical and emotional
symptoms including depression, anxiety, restlessness therefore certain treatment and
medication are prescribed to reduce these symptoms that makes it easier to stop the drug
use .e.g. Antidepressants

2. STABILIZING OR STAYING IN TREATMENT.

Some medication are used to help the brain adapt gradually to the absence if the abused
drug.
These drugs stave off drug craving and having calming effect on the body systems,
They include,
a. Tobacco addiction
- Nicotine replacement therapy
- Bupropion
- Varenicline
b. Opioids addiction
- Methadone
- Buprenorphine
- Naltrxone
c. Alcohol and drug addiction
- Naltrexone
- Disulfiram
- Acamprosate

3. PREVENTING RELAPSE
- Drugs experience and exposure to drugs are most common triggers for relapse.
- Medications which helps to prevent relapse therefore promoting patient‟s recovery.
- Psychotherapy.
- Occupational therapy.

4. REHABILITATION (EXTENDED CARE PROGRAMME)

- Contingency management
Uses of positive reinforcement such as providing rewards or privileges for remaining drug
free, for attending and participating incounselling sessions and taking prescribed
medications.
- Family therapy.
Approaches a person‟s drug problems in context of family interactions and dynamic that
may contribute to drug use and other risky behaviors.
Group therapy.

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Question 12

a) Outline the causes of malnutrition in the community

b) What is the role of a nurse in the prevention of malnutrition in the community?

Definition of terms

Community;
Is a group of people living in the same locality, having the same services enjoying life together eg
in places of worship, market places and share the true problems like famine, epidemics etc.

Malnutrition;
Is the result of deficiency of proteins, carbohydrates, minerals as well as vitamins leading to loss
of body fats and muscles, tissues and vice-versa. It can be either under or over nutrition.

Causes;
They are divided into two;

Physical factors
Chronic ill health; like HIV infection whereby a patient will have excessive diarrhea leading to
loss of nutrients in the body hence leading to under nutrition.
Worm infestation in the body; this leads to excessive extraction of absorbed food nutrients from
the body leading to under nutrition.
Congenital abnormalities; like pyloric steno sis which is characterized by excessive projectile
vomiting making the loose nutrients leading to under nutrition.

Social-cultural factors
Ignorance; some people in the community have inadequate knowledge on how to have a
balanced diet in their homes thereby ending up feeding on one type of food nutrient leading
under nutrition or excessive taking of various nutrients leading to over nutrition.

Poverty; people will lack enough money to provide food needed by the family members hence
leading to under nutrition.

Weaning; some parents tend to over feed their children excessively than what is required in their
bodies predisposing them to over nutrition and vice versa.

Lack of food due to poor methods of storage; which can lead to spoilage of available food
making people suffer from hunger leading to under nutrition.

Un sanitary methods of food preservation; can lead to contamination of food hence infecting
the people who will eat the food leading to infections like diarrhea hence under nutrition.

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Political instability; which will lead to migrations whereby people may suffer from famine
leading to inadequate feeds hence under nutrition.
 Cultural taboos
 Large families
 Natural calamities like floods, droughts, etc.
 Family instability.
 Death of care takers at home.
 Meal pattern within a home.

Roles of a nurse/midwife in prevention of community malnutrition

They are divided into 3 levels;
Primary level of prevention
This involves preventive measures before the occurrence of malnutrition in the community. These
includes;
 Health education; she health educates the community about preventive, curative and
rehabilitative measures of malnutrition.
 Immunization; she encourages community members to take their children for immunization
against communicable diseases.
 Encouraging income generating activities in order to earn a living.
 Family planning; encourage people to take up small families they can take care of.
 Promotion of girl child education.
 Advocate for enough good food storage.
 Proper weaning
 Encourage a well-balanced diet
 Early collection of congenital abnormalities.
 Maintenance of hygiene to prevent illnesses
Secondary prevention
 Carrying out population screening to identify people with malnutrition and immediate
referral to reduce the illnesses before becoming severe.
 Case management where patients are started on nutritional intervention programmes.
 Maintaining sanitation both personal and communal.
Tertiary prevention
This involves innervations to prevent re occurrence of malnutrition in the community. They include;
 Encourage drug compliance
 Encourage the community to educate the girl child
 Encourage follow up to assess the effectiveness of your interventions
 Educate the public on various economic activities to earn a living.
 Improve on medical facilities including maternal and child health services in the community.

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 SURGERY QUESTIONS
Question 13
A thirty year old lady has sustained severe burns of the abdomen?
a) Describe his management up to 72hours.
b) Explain the complications of burns.
Solution
Management of burns for 72hrs
Aims;
 To control and prevent shock
 To replace fluids
 To prevent infections and other complications
Admission
The patient is admitted in surgical ward in a bed for burns with sterile sheets and bed cradle to
lift off the eight of beddings on wounds
Nurse patient relationship is established and particular are taken
Observation: observations are done both vital and general much emphasis is put on the general
ob‟s which includes the level of consciousness, percentage burnt and the depth of burns.
Observations are continued throughout the patient‟s stay in hospital.
Inform Dr. the Dr is informed who will also assess the patient and order for investigations
Investigation
Blood for HB, group and X-match
Treatment
Includes fluid replacement to prevent and treat shock, several formulas can be used to calculate
fluid replacement e.g. parkland‟s formula the parkland formula for the total fluid requirement in
24hrs is as follows; 4ml x TBSA (%) x body weight (kg), 50% given in first eight hours and 50%
given in next 16hours.
Analgesics: strong pain killers like pethidine 50 – 100mg 8hrly x 24hrs in severe cases then when
condition improves mild analgesics like paracetamol 1gm 8hrly for 3days are given.
Antibiotics to combat infection like inj. Ceftriaxone 1 – 2gm o.d in acute phase for at least 5 – 7
days or caps Ampiclox x 500mgs 6hrly orally for 5 – 7days.
Oxygen administration may be required in case of odema of the upper respiratory tract that
may case difficult breathing.
Anti-tetanus toxoid injection 0.5mls stat to prevent tetanus.

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Specific nursing care
Wound care: the wounds should be given much attention which will include daily dressing with any
of the following honey, normal saline, pawpaw, iodine or as ordered by the surgeon observe the
wound for signs of inflammation.
Hygiene: patient‟s bed is kept dry, bed made daily using sterile bed sheets, use of bed cradle to
lift off the beddings. In acute phase patient may not necessarily need a bed bath clean towel
with soap may be used to clean the area which is not burnt, mouth care encouraged daily, wound
kept clean.
Diet: in acute phase a patient is kept on IV fluids, NGT may be passed with extensive burns of the
abdomen for feeding, patient is feed on highly nutritious diet with plenty of oral fluids.
Exercises: passive exercises are encouraged especially breathing exercises and limb movements,
active exercises are also done once patient‟s condition improves.
Observations: vital observations that are T.P.R and BP these are monitored half hourly in acute
phase. Then continued as patient‟s condition improves at least twice a day including the general
observations.
Rest: ensure patient gets enough rest but minimizing visitors, control noise in the ward.
Medication: drugs are administered according to Dr.‟s prescription following the 5‟Rs.
Bladder care: catheter is passed for easy monitoring of input and output the fluid balance chart
balanced every after 24hrs.
Psychological care: re assure patient, comfort her.
Health education: health educate patient and care givers on what caused the burns and how to
prevent further occurrence of such incidents
Complications (early and late complications)

 Severe pain due to exposure to nerve endings

 Shock due to severe pain and excessive loss of fluids
 Respiratory failure due to edema of respiratory tract
Late

 Severe pain due to excess loss of fluids and failure to replace fluids in time.
 Overwhelming infection at the burn site which can progress to septicemia and secondary
infection of any part of the body.
 Extensive oedema at the burn site and to some extent it accounts for the loss of fluids from
circulation.
 Oedema in the upper respiratory tract which can obstruct the airway.
 Respiratory failure as a result of extensive burns which causes changes in the lungs even
where no inhalation of smoke has occurred.
 Renal failure which may be due to blockage of renal tubules with hemoglobin released in
to the circulation from the many RBC‟s destroyed by deep burns.

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  Gastro intestinal bleeding as a reaction to extensive burns a duodenal ulcer develops as
curling‟s ulcer.
 Keloids scars these are excessive masses of scar tissue leading to great disfigurement
these can be prevented by use of skin grafting.
 Anemia due to initial destruction of RBC‟s or gastro intestinal bleeding.
 Scar hypertrophy and contractures most scars shrink and they cause disabling contractures
most scars shrink and they cause disabling contractures limiting the movement of the joint.
Question 14
a) Define thyrotoxicosis.
b) Outline the clinical features of thyrotoxicosis
c) Differentiate between hyperthyroidism and hypothyroidism.
Solution
a) Thyrotoxicosis: This is a condition occurring due to excessive secretion of thyroxin hormone.
b) Clinical features of Thyrotoxicosis

 Its gradual onset with a moist skin

 Profuse sweating where by a cold weather is preferred than sunny weather
 Protruding eyes (exophthalmos) the eyes are starting with a frightened look
 Marked loss of weight despite good appetite
 Fire tremor of the fingers
 The patient is hyper excitable
 Diarrhea and vomiting may present due to over activity of the intestinal tract
 Menstrual disturbances may occur e.g. amenorrhea
 High blood pressure and pulse rate
c) Differences between hyper and hypothyroidism
Hyperthyroidism Hypothyroidism
Associated with high thyroxin levels Very low thyroxin levels
Increased appetite Low appetite
Weight gain Weight loss
Frequent bowel movements with diarrhea No frequent bowel movements
Heat intolerance Heat tolerance
Increased heart palpitations No heart palpitations
Increased sweating No increased sweating

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Question 15
Samuel a 30 year old peasant has been presented to OPD with all the features of tetanus.
a) Describe his management from admission up to discharge
b) Outline the clinical features of tetanus.
Solution
Management of tetanus
Aims of management;
i. Control spasms
ii. Destroy the circulating toxins
iii. Prevent complications
Admission: the patient is admitted on a surgical ward, isolated in a quiet room since a slightest
noise or flicker increases the spasms. A patient is nursed in dark room due to photo phobia, door
fitted with suitable spring to prevent banging/ slamming, the nurse must warm hands before
touching the patient to avoid stimulating further spasms.

 Nurse patient relationship

 Observations: vital and general observations done much emphasis is put on spasms, note
the frequency, duration and strength.
 Inform the doctor who will examine the patient and order for investigations.
 Investigations: no specific lab test may be done but other tests like lumber puncture may
be done to rule out meningitis
Treatment may include:

 Antibiotics like inj. Ceftriaxone 1-2gms o.d for 1 week

 A tetanus immunoglobulin is administered IM to reverses the poison
 Muscle relaxers such as diazepam
 Sedatives
 Oxygen administration and tracheostomy may be indicated in severe cases and suction
applied at regular intervals
The drug administration chart
DATE TIME DRUG ROUTE DOSE SIGN
14/03/2015 3:00pm Valium 10mg i.v NT
“ 6:00pm Lagactil 50mg NGT “
“ 9:00pm Valium 10mg i.v “
“ 12:00mn Lagactil 50mg NGT “
“ 3:00am valium 10mg i.v “

The doses can be reduced as the condition improves and per doctor‟s orders

36
Specific nursing care
Spasm chart
The duration, strength, frequency and severity of spasms should be noted on the spasm chart.
Date Time Frequency Duration Strength Cause Sign
23/07/2014 2:00pm Every 10 3 seconds strong noise BT
minutes

 Diet: tetanus spasms increase high metabolism and catabolism so a high nutrition and fluid
intake should be encouraged to neutralize toxins. During the acute phase a nasal gastric
tube is passed for feeding and fluid balance chart should be strictly maintained
 Observations: vital observations T, P, R and BP theses are taken at least 4hourly in the
acute phase later twice a day as condition improves, specific observations done on the
spasms note frequency, duration e.tc.
 Hygiene in the acute phase patient is kept clean, mouth are done
 Bed rest: patient is nursed in a non-stimulating environment with dim light and reduced
noise
 Care of the wound: surgical toilet to clean the wound and remove the source of the
poison (debridement). The wound is irrigated with hydrogen peroxide; it should be left
uncovered because the tetanus bacillus will not grow in the presence of oxygen. The
wound is not sutured.
 Bladder: in acute phase a catheter is passed removed when the condition stabilizes.
 Medications: drugs are administered following doctor‟s prescription.
 Exercises: active exercises are restricted during the acute phase but passive are done
when the condition improves active exercises are also done.
 Nurse patient relationship
 Health educate on the tetanus mode of spread and clinical presentation.
 Discharge when the condition improves, the catheter and NGT are removed and patient
discharged with advise
Advice on discharge

 Putting on gum boots when digging

 Covering all the wounds
 Avoid applying cow dung on the wounds
Features of tetanus

 History of a wound which may even have healed

 Temperature is usually normal until later when infections set it
 Sweating
 Elevated blood pressure
 Rapid heart beat
 The first diagnostic symptom is slight spasms and stiffness in the jaw muscles (as the
disease progresses the classical picture of tetanus appears).

37
  Patient is anxious, but mentally alert
 The patient back is arched and head thrown back (opisthotonos position)
 Stiffness of the neck muscles
 Spasms of the facial muscles leading to difficulty in opening the mouth (trismus)
 Drawing up of the angle of the mouth which gives a rise to the characteristic smile risus
sadonicus.
 Difficulty swallowing
 Stiffness of your abdominal muscles
 Spasms of the sphincter muscles of the body which renders swallowing, defecation and
micturition very difficult.
 Spasms of respiration leading to long periods of anoxia until death ensures
 Painful body spasms lasting for several minutes typically triggered by minor occurrences
such as loud noise, physical touch or light
 Photophobia
 Irritability
 Excessive sweating
 Hand or foot spasms
Question 16
A seventy year old man is admitted on surgical ward with acute retention of urine.
a) Outline the signs and symptoms of benign prostate hypertrophy.
b) Describe the post-operative nursing care following prostatectomy up to discharge.
c) Explain 7 complications following prostatectomy
Solution
a) Signs and symptoms of benign prostate hypertrophy
 Frequent micturition here is disturbed with nocturnal micturition
 Urgency
 Precipitancy
 Difficulty micturition
 Hematuria due to congestion of blood vessels around the bladder neck
 Pain on micturition which develops from infection of residue urine
 Acute retention of urine may develop if not relieved patient may go in renal failure
 Enlargement of the gland may be felt on rectal examination
b) Post-operative management

 Post-operative bed: the bed is made up with all its requirements after the operation a
patient is received from theater with a written and verbal report, patient‟s observations
are taken, level of consciousness noted and patient is wheeled on the ward.
 Position: the patient is put in semi prone position when the patient is fully awake is put in a
recumbent position
 Observations: the patient‟s general condition is observed, vital observations taken like
pulse, respirations, blood pressure and pulse ½ hourly, 1hourly, 2hourly, 4hourly when the
patient is stable then they are taken twice a day the catheter and other drainage tubes
are observed to see if they are not blocked observe for proper draining, note the colour

38
 of the urine report if the colour of urine is less blood stained or increasingly blood stained,
observe the suture line for bleeding.
 Medication: administer drugs as ordered by the doctor these will include analgesics like
pethidine 100mg IM 8hrly for 24hrs the injection diclofenac IM 8hrly for 24hrs then later
tabs paracetamol 1gm 8hrly for 3 days, antibiotics like ceftriaxone 1-2gms o.d for
5days, iv infusion n/s alternate with dextrose as ordered by the doctor. The fluid balance
chart should be properly filled and balanced every after 24hrs
 In case of severe hemorrhage blood transfusion may be done with whole blood
Specific nursing care

 Hygiene: theater gowns are removed once a patient is stable, bed bath offered, soiled
linen replaced with clean linen, beddings kept clean and dry. If the patient stabilizes is
encouraged to take the shower daily and mouth care done twice per day
 Care of the catheter: from the theatre a patient is on continuous bladder irrigation using
normal saline and a catheter in the situ, irrigation is only stopped when the catheter
drainage is fairly clear. The catheter is removed on the 2nd or 3rd day if it was a trans
urethral prostatectomy. After transvesical prostatectomy it‟s removed on the 5th – 7th day
post operatively. The drain is removed after 48 – 72hrs post operatively unless there is
excessive bleeding
 Diet: nil per oral in the first few hours after operation but on IV fluids to help rehydrate
the patient. The doctor will introduce food and fluids slowly once the patient is stable,
benign with sips of water a high oral fluid intake must be maintained at least 2- 3l to
wash the bladder and prevent the risk of infection a patient is encouraged to pass urine
regularly by the c lock (1/2 to 1hrly) the time interval is gradually increased so that after
2 -3 days the patient passes urine
 Exercises: breathing exercises and limb movements are encouraged in the acute phase
then as the patient‟s condition improves he‟s allowed to ambulate
 Rest: ensure patient gets enough rest by minimizing visitors, administer drugs in time
minimize the noise in the ward
 Nurse patient relationship continued
 Repeat investigations like Hb, FBC if condition is satisfactory patient can be considered for
discharge
Discharge

 5 days following a trans urethral prostatectomy a patient may be discharged for open
prostatectomy discharge is considered after 7 – 10 days once the condition improves. The
patient is instructed to drink plenty of oral fluids for 3 months and he is told that a little
bleeding may occur from time to time.
 To take drugs given following discharge
 Have enough rest at home
 Restricted from doing heavy work up to when he has totally improved
 To come back for review on the given date

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c) Complications of prostatectomy

 Hemorrhage: it may be secondary or primary

 Infection: urinary infection may occur following prostatectomy
 Deep venous thrombosis: this is the formation of a blood clot. It can be life threatening if it
dislodges and travels through the blood vessels to the lungs.
 Clot retention: the catheter may stop draining following a blood clot formation in the
bladder. The clots may be small or large amounts blocking the catheter.
 Injury to the nearby organs or structures: the rectum, bladder and Ureters are close to the
prostate and may be accidentally injured by surgical instruments.
 Impotence: the inability to get and erection
Question 17
Mr. Kakembo has been diagnosed with peritonitis in OPD Lubaga hospital.
a) Define peritonitis
b) Outline the causes of peritonitis
c) Mention the signs and symptoms of peritonitis
Solution
a) Definition
Peritonitis: is the inflammation of the peritoneum (a thin and vascular membrane that lines the
abdominal cavity).
b) Causes of peritonitis

 Abdominal wounds penetrating the peritoneal cavity

 Perforated acute peritonitis
 Perforated gastric or duodenal ulcer
 Acute pancreatitis
 Rupture of the intestines, the rectum or bladder secondary to inflammation or obstruction
 Perforated diverticulitis
 Ruptured ovarian cyst, rupture of the uterus or fallopian tubes
 Ruptures spleen or liver (closed abdominal trauma
 Closed abdominal causing a rupture of an organ like the spleen, liver etc)
 Inflammation of an organ local peritonitis e.g. appendicitis, cholecystitis
 Escape of the gastro intestinal contents or contents of another organ general peritonitis
e.g. perforated peptic ulcer, ruptured gall bladder, ruptured ovarian cyst.
c) Signs and symptoms of peritonitis

 Gradual onset with mild pain in the right iliac fossa which later becomes severe and
constant
 Rigidity and tenderness of abdominal muscles
 Frequent and profuse sweating
 Patient becomes weaker, lacks sleep and looks toxic
 Abdominal distension

40
  Diarrhea which may profuse
 General weakness
 Raised temperature, pulse is rapid irregular with a weak volume
Question 18
A twenty five year old year lady has been diagnosed with intestinal obstruction.
a) Mention the causes of intestinal obstruction.
b) Describe the pre and postoperative management up to discharge.
Solution
a) Causes of intestinal obstruction

 Mechanical (dynamics) causes may  Hernia strangulations

be mural or extra mural  Intussusceptions
 Abnormal tissue growth  Tumor‟s blocking the intestines
 Adhesions or scars tissue that form  Volvulus (twisted intestines)
after surgery  Round worms
 Foreign bodies (ingested materials
that obstruct the lumen)
A dynamic causes/paralytic causes

 Mega colon
 Excessive handling
b) Management of intestinal obstruction (it’s an emergency)

 Admission: patient is admitted on the surgical ward, all admission procedures quickly done
 Nurse patient relationship: both patient and relatives are welcomed and reassured
 Observations: vital observations, specific and general observations are taken on admission
and later continued routinely
 Assessment: doctor will assess and examine patient then order for investigations
 Investigations:
 Plain abdominal x- ray
 Ultra sound scan
 Hematology
 Rectal examination
 Urinalysis
Pre-operative management: this is done after failure of conservative treatment (team work)

 Resuscitation with iv fluids

 Explain the nature of procedure to the patient so as to obtain an informed consent
 NGT for aspiration to empty the stomach
 Take off blood for Hb, group and x – match and book 2 units of blood
 Patient is kept nil per oral but maintained on iv fluids manually removal of faeces if it is
the cause
 Pass the NGT and urinary catheter

41
  Shave the patient
 Administer pre medications
 Remove patient‟s jewelry
 Make a post-operative bed
Specific post-operative care

 Position: from theatre patient is put in semi prone position with head turned to one side to
easy drainage of secretions
 Medications: patient is put on strong analgesics like injection diclofenac 75mgs IM 8hrly
for 48hrs then when pain subsides patient is given oral analgesics like paracetamol 1gm
8hrly for 3 days
o Antibiotics: IV flagyl 500mgs 8hrly for 5 – 7 days, injection ceftriaxone 1 – 2gms
o.d for 1 week, iv fluids normal saline alternate with dextrose
 Observations: do vital observations, observe the suture line for bleeding, aspirates for
smell, colour note the amount, when the aspirates are clear or finished the NGT can be
removed on the doctors order. It should be recorded on the fluid balance chart
 Diet: keep the patient nil per oral until aspirates are clear or doctor orders but continue
with oral fluids, when bowel sounds are back patient may be starts on the sips of clear
fluids then slowly started on the light diet, intravenous drips discontinue the full diet is
achieved
 Wound care: the wound is observed for bleeding or oozing, dressed changed when soiled
sutures removed on the 7th day or no alternative days, for absorbable sutures they are
not removed
 Fluid balance chart: this is properly recorded, the input and output then balanced every
after 24hours
 Exercises: passive exercises are done in the acute phase then later active exercises done
this improves on patient‟s circulation and prevents DVT
 Hygiene: patient kept clean, daily bed bath done in acute phase when the condition
improves patient is encouraged to bathe himself, oral care done, patient‟s bed kept clean
with timely change of bed clothes
 Give the general nursing care
 Discharge the patient can be considered for discharge when the condition improves and
advice is given on discharge as follows:
 To take all the drugs prescribed
 Have enough rest at home
 Report back on a given date

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Question 19
Joseph a thirty three year old lady has been presented to OPD with all the features of
osteomyelitis.
a) Define osteomyelitis.
b) Outline the clinical features of osteomyelitis.
c) Describe the management of Joseph up to discharge.
Solution
a) Definition
Osteomyelitis: is the inflammation of bone (bone infection)
b) Signs and symptoms of osteomyelitis

 Sudden onset of chills

 Fever
 Tachycardia
 Malaise
 Tenderness, redness and warmth in the area of the infection
 Swelling around the affected bone
 Difficulty or inability to use the affected limb or bear weight or walk due to severe pain
 Lethargy or irritability in young children
 Offensive discharge from the site of infection
 Bone stiffness and nausea
 Loss of function
c) Management
Aims;

– Control of infections
– To treat the infection
– Prevent complications
Admit in severe cases or treat as an outpatient in mild conditions
Take particulars and vitals observations
Assessment
Doctor‟s orders for the following after his assessment
Investigations

 Bone X – ray  ESR

 Radio isotope bone scan  Pus swab
 WBC  MRI
 FBC  Bone biopsy

43
Treatment

 The gold standard treatment of osteomyelitis includes antibiotic therapy as well as surgery
to remove any area of the bone that is dead or infected
 In mild disease ciprofloxacillin 750 – 500mg bd 4 – 6 weeks or levofloxacillin 750mg
bbd for 4 – 6 weeks or ceftriaxone 1 – 2gms o.d for 4 – 6 weeks, Augmentin 500mgs
8hrly for 4 – 6 weeks, children respond very well on cloxacillin 125 – 250mgs 6hrly for 4
– 6weeks
 In severe diseases ciprofloxacillin + clindamycin 600mgs 6 – 8hrly for 6 weeks or
ampicillin + ciprofloxacillin 500mgs bd for 4 – 6 weeks
 Analgesics can also be given like tabs ibuprofen 400mgs 8hrly for 5 days to control pain
 Debridement, here the area is opened up around the infected bone and any fluid or pus
that might have accumulated in response to the infection is drained this can be done under
general anaesthesia, obtain consent and prepare patient for theatre in cases of
debridement
 With extensive bone damage skin grafting and bone graft may be required, this graft
aids the body repairs any blood vessels damaged as well as form new bone
Specific nursing care

 Wound care: daily dressing with normal saline, hydrogen peroxide etc
 Diet: the patient should feed on highly nutritious diet with plenty of oral fluids fruits to
promote quick recovery
 Rest: minimize noise, control visitors, make patient in bed
 Exercise: both passive and active exercises should be encouraged to prevent DVT
 Hygiene: ensure proper hygiene, encourage patient to bathe daily care of the mouth and
daily oral care
 Fluid balance chart
 Sleep
 Bowel and bladder
When patient‟s condition improves can be discharged on treatment
Advice on discharge

 Advise the patient to have enough rest

 To take all the drugs prescribed
 To take a well balance diet
 To come back for review on a given date

44
Question 20
a) What is blood transfusion?
b) Describe five complications that may occur due to blood transfusion.
c) What would cause failure of a blood drip to run during blood transfusion?
d) Explain the nurse’s responsibility before, during and after blood transfusion.

Solution
1. Define blood transfusion.
This is the intravenous replacement of the lost or destroyed blood with compatible human
blood
TYPES OF BLOOD PRODUCTS
Whole blood
It‟s composed of packed cells, platelets, fresh frozen cells and plasma. This restores blood volume
and therefore oxygen capacity.
Red blood cells
It‟s also composed of packed cells. It‟s indicated in hemorrhagic shock, symptomatic anaemia with
hemoglobin less than 8g/dl.
Platelet concentrate
Platelet may be administered to aid homeostasis in patients with thrombocytopenia. Its indicated
in treatment of non surgical bleeding due to thrombocytopenia.
Plasma
This is a fluid part of blood after centrifuging in order to remove the blood cells. It‟s used to
expand blood volume in order to wait for blood to be cross matched.
b. Explain the complications of blood transfusion.
ALLERGIC REACTIONS
Some patients may be hypersensitive to some substances contained in blood which he/she is
receiving.
Patient present with the following clinical features namely Itching, anaphylactic shock, flushing,
urticaria and signs of respiratory distress.
Management

 Stop the infusion immediately,

 Urgently inform the doctor
 Give antihistamine if prescribed like promethazine hydrochloride 25 – 50mg deep IM or slow
IV.

45
 If there is anaphylactic feature like bronchospasms, strider, give hydrocortisone 4mg/kg IV
and aminophylline 6mg/kg iv which causes dilatation of the bronchioles.
INCOMPATIBILITY REACTION:
This is a serious reaction. It occurs when the donor‟s blood is not compatible with that of the
recipient.
Present clinical features are:-

 Chills, shivering, headache, nausea, law back pain, sometimes vomiting, haemoglobinuria
and acute renal failure.
Management:

 Stop the infusion immediately and notify the doctor.

 Keep the vein with normal saline
 Keep blood for rechecking at the blood bank
 Take blood samples from the site
 Collect urine specimen to determine haemoglobinuria.
 Give diuretics as prescribed by doctor when furosemide 1 mg/kg IV
– Febrile reaction:
– While transfusion is in progress, the patient may develop fever accompanied by
clinics, headaches.
Management:

 Stop the transfusion at once and notify the doctor.

 Treat the patient symptomatically such as giving him an extra blanket.
 Give antipyretic s if prescribed PCM I g tds x 3/7 adult.
Note
It‟s very important to take observations before transfusing a patient like temperature, BP, pulse
and respiration.
Circulatory overload
If the volume of blood administered is greater than what the circulatory system can conveniently
accommodate, the patient will have;
Distended neck vein, Dyspnoea, Dry cough and pulmonary oedema.
Management

 Stop the transfusion and notify the doctor who may order to stop completely.
 Put the patient in sitting up position supported by four pillows.
 Maintain airway and give high flow oxygen by mask.
 Give diuretics e.g. furosemiderosemide I mg/kg IV to increase retention in the renal tube
thus decreasing pulmonary oedema.

46
AIR EMBOLISM:
Small sticky bubbles of air block pulmonary artery when are enters the circulatory system and the
patient will suffer from the following clinical manifestations.
Hypotension, tachycardia, cyanosis, loss of consciousness.
Management:

 Before expel air from the infusion tubing and needle or cannula before administering the
infusion.
 Avoid leaving the bottle getting completely empty to prevent air from fro entering the vein.
 Patient is instructed to call the nurse before he bottle gets finish.
 Immediately atop the infusion by clamping the tubing of giving set.
 Position the patient turning him/ her on his left side with his had turned down ward to avoid
air entering the pulmonary circulation
 Notify the doctor
 Administer oxygen.
PYOGENIC REACTION
The blood or equipment for giving the blood may be contaminated with bacteria and the patient
will present with the following.
High fever, chills, nausea and vomiting
Management
Stop the infusion immediately

 Tepid sponge the patient

 Inform the doctor and blood bank
 Monitor the vital signs
 Return the blood to the blood bank
 Give antibiotics and antipyretics as prescribed by the doctor like Amoxycilline 500mg,
Paracetamal 1g
SPEED SHOCK
This happens when the blood has been administered very quickly hence causing a systemic
reaction known as a speed shock.
Management

 By regulating the flow rate carefully according to the doctor‟s order.

 If it occurs, stop the infusing immediately.
 Notify the doctor and carry out his orders.

47
 INFILTRATION REACTION
This is the escape of blood in to the surrounding tissues. It may be due to dislodged cannula or
the needle may puncture the posterior wall of the vein.
Presents with the following; - pain, swelling and cold at the site.
Management:

 Discontinue the infusion restart at another site.

 Teach the patient to avoid unnecessary movement of the infusion arm.
 Warm compress at the site to reduce pain and swelling.
Introduction of infections

 Like HIV, HEP B virus, malaria and syphilis if blood was screened when the donor was still
in the window period.
 Sepsis due to failure to observe surgical aseptic techniques.
 Renal failure due to red blood cell agglutination (formation of antigens and antibodies
precipitate).
 Thrombophlebitis which is the inflammation of the vein with clot also can interfere with
 Citrate intoxification due to too much sodium citrate used. ( Its used as a preservative of
blood) Here the patient gets brandycardia as a cardinal feature.
c. What would cause failure of blood drip to run during blood transfusion?

 When the cannula is not in the site

 Swelling around the site.
 Unnecessary movement of the upper limb.
 Infiltration of the blood vessels during passing the cannula.
 Clot formation in the blood vessels.
 Low height of the drip stand
 Kinking 0f the blood vessels
d. Explain the nurse’s responsibility before, during and after blood transfusion.
BEFORE BLOOD TRANSFUSION

- The blood sample is taken to the laboratory by a nurse to check for hemoglobin level, group,
Rhesus factor and cross matching.
- Get the blood results from the laboratory.
- Explain the procedure to the patient if the hemoglobin levels are low.
- Make the patient to consent.
- Check whether blood has been screened for any infections eg HIV AND Hepatitis.
- Blood is checked by two staffs on the ward and one of them should be registered nurse and
another qualified nurse.
- Warm the blood to match with the body temperature.
- Give psychological care i.e. re-assures the patient.
- Take vital observations like temperature, pulse, respiration and carry out general examination
of a patient like cyanosis and record on the transfusion observation chart.

48
- Check the label on the blood unit i.e. it should have patient‟s name, ward, Rhesus factor, blood
group and expiry date.
- Bed pan, urinal and food are offered to the patient to avoid the bowel disturbance.
- Clean the puncture site, wash and shave if necessary.
- Establish an infusion line to connect blood ensuring aseptic techniques.
- Elevate the arm with a pillow.
- Give pre-medication e.g. furosemide 1mg/kg in case of whole blood and connect blood
During transfusion
The nurse should

 Continue giving psychological care.

 Constant supervision and monitoring of the patients.
 Blood flow regulation i.e. either slow in conditions like anaemia and cardiac conditions or
higher in conditions like haemorrhage.
 Take vital observations every after 15minutes fro the first hour, then ½ hourly till complete.
 Introduce a fluid balance chart to monitor the output i.e. amount and observe for any colour
change.
 Observe for any reactions and manage accordingly e.eg pyrexia, rigors etc.
 Observe the punctured site for swelling, tenderness and leakages.
 Ask the patient to report any abnormal feeling e.g. headache, backache etc.
After transfusion

 Take vitals for ¼ hourly for the 1st hour, ½ hourly for the 2nd hour and 4hourly four the
25hours.
 Keep empty bottles on ward for investigations in case of post transfusion reactions for 24
hours.
 Collect blood sample for post hemoglobin to check for effectiveness of the procedure.
 Record details of transfusion including serial number of bag, time at which blood was
transfused and blood group.
Question 21
A thirty year old lady has sustained severe burns of the abdomen?
a) Describe his management up to 72hours.
b) Explain the complications of burns.

Solution
Burns are wounds caused by energy transfer from the heat source to the body, heating the tissue
enough to cause damage.
Burns injuries have many causes and the most common causes include; flames, contact with hot
fluids, chemicals, electricity and radiations.

49
Management for 72 hours
This is an emergency which requires quick intervention and team work
Aims of management
– Admission in an isolated ward or Burns unit in the burns bed.
– Alleviation of pain.
– To promote quick healing.
– To prevent complications such as shock.
– Prevention of infection.

Phase of burn care: Care is divided into emergency/resuscitative phase and acute/intermediate
phase.

Emergent phase/resuscitative
It‟s from onset of injury to the completion of the fluid resuscitation.
 First aid
 Prevention of shock
 Prevention of respiratory distress
 Detection and treatment of concomitant injuries
 Wound assessment and initial care

Acute /intermediate phase

From the beginning of diuresis to near to completion of closure of the wound.
 Wound care and closure
 Prevention of complications
 Nutritional support
Emergent/ resuscitative phase
 Prevent injury to the rescuer
 Remove the victim from the source
 Douse with water and never use cold water
 If chemical burns, carefully remove clothes and flash the wound with larger amounts of
water
 If its electrical burns and the victim is still in contact with the electrical source, do not touch
the victim
 ABC. Is assessed
 Airway breathing and circulation. Breathing must be assessed and patient‟s airway should
be established immediately during initial minutes of emergency care. Oxygen can be
administered
– Check peripheral pulse to assess circulatory status
– Assess and initiate treatment 4 injuries
– Remove tight clothing‟s and jewelry
– Cover victim with clean clothes to prevent heat loss
– Position in spine position.
Nb. Never apply ice directly to the burn.

50
 If possible remove the clothes immediately adherent clothes a left in place once cooled jewelry
and others may be removed to allow for assessment and prevent constriction secondary to rapid
developing edema.

Cover the wound

The wound should be covered as soon as possible to minimize bacterial contamination and
decrease pain by preventing air from coming into contact with the injured surface.

Sterile dressing is best but any clean dry cloth can be used as an emergency dressing.

NB: Ointments and salves should not be used.

 Patient is reassured plus his care takers
 Stabilization in terms of fracture immobilization ,injuries and hemorrhage treated
 A large bore iv line is inserted and fluids are given to prevent and treat shock
 Patient is treated for pain with any appropriate opioid analgesics such as pethidine.

Any accurate history is obtained,

 To determine any complications severity and any associated trauma. medical history
should also be obtained
 Patient should be transported to any health facility and burn care treatment are
explained to the family and the patient

At hospital
Admit the patient in resuscitation room
Position the patient on the spine position
Take brief history from care takers and the reassure them
Vital observations ie TPR BP,SPO2 may be taken and the docter is called if notaround hu will
order for
IV fluids; ringers lactate or normal saline to be given with in 24hrs i.e.
Calculated by; surface area burnt* body weight*4mls/kg.
With the 1st half of the total fluid given in the 1st 8hrs and the 2nd half infused in the remaining
16hrs.
Pethidine injection 8hrly for 3days then diclofenac 75mg 8hrly for 3days.
Tetanus toxoid 0.5ml stat to prevent tetanus infection. If not available then anti tetanus
serum1500iu is given i.m after attest dose of 0.1 intradermal.
At the ward
The patient isadmited on a surgical ward (burns unit.) well ventilated and clean.
The patient is put a sterile bed for burns and positioned on a spine position.
Use of a bed cradle, mosquito net and extra blanket must be provided to provide extra warmth
Anti-biotic
 Inj. Gentamycin 160mgs iv 12hrly for 5days
 Topical silver nitrate solution 0.5%.
 Topical silver sulfadiazine 1% cream
 Iv ceftriaxone1g b.d for 5days , for prophylaxis against infections
 IV metronidazole 500mg 8hrly for 3-5days
Blood transfusion after 24hrs of iv fluids may be given at 30mls of blood per %age of deep
burns

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Sedatives: Diazepam 10mgs iv nocte 3days

NB. All assessments and treatment must be documented in the patients file.
Bladder care
If the patient is conscious should be encouraged to pass urine or a catheter is passed if the patient
z unable to pass urine…

NB: Every urine passed is measured and amount recorded in the patients file
Bowel care
Ensure that the patient opens the bowel or give the patient enema

Surgical treatment
 Surgical toileting
 Dressing of the wound. This should be done daily to prevent the invasion of micro
organisms
 Plastic surgery in order to restore function
 Grafting and debridement

Acute / intermediate phase

Begins 48-72 hrs
Attention is directed to:
 Continued assessment and maintenance of respiratory and circulatory status
 Fluid and electrolyte balance plus gastro intestinal function
 Infection prevention
Burn wound care i.e.;
– Wound cleaning
– Topical anti biotic
– Wound dressing
– Wound debridement and grafting
 Pain management by administering of opioid via the intra venous route
 Nutritional support
– Dietary consultation is useful in helping patients meet their nutritional needs
– Vitamin and ferrous sulphate supplement diets
 Psychological care
– This is directed to both the patient and the care takers. Reassurance is very vital in this
state.
Nursing care

Observations
Vital signs are taken 4hrly and if initial risk of infections is not present, then continued 12hrly
daily.

Vital observations include; temperature, pulse respiration and blood pressure. And it should be
charted in the patients file. In case of any abnormality we inform the doctor.

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Hygiene
 Bed bath is given daily
 Skin care
 Routine care for all pressure areas
 Eye ears kept clean
 Nails cut short
 Bladder. Catheter removed in 48hrly
 Oral care given to prevent infection and improve on the patients appetite
 Bed for burns should be made properly
 Ward cleaning

Exercise
This should be done regularly as patient recovers
 Deep breathing exercise
 Ambulation of legs, the frequent changes of position
 Contracture exercise given to stretch the scar tissue

Diet
Patient should be fed on a well-balanced diet full of;
 Proteins
 Carbohydrates
 Vitamins i.e. vit C that helps quicken wound healing

Elimination
The bowl and the bladder are taken care of. In acute stages urinary catheter is passed and
maintained.

Plenty of fluids and roughages are given to avoid constipation. Fluid balance chart should be put
to maintain the fluid intake and output until danger of shock and renal failure passed.

Care of the wound

This is archived in 2 ways
Open method
This involves cleaning of wound with normal saline and application of iodine
Closed method
This involves cleaning with saline and then cover with 4 layers
 1st layer sulphadizine cream
 2nd dry gauze
 3rd gauze pad
 Crepe bandage
Rest and sleep
This should be ensured by
 Switching off the lights
 Limit visitors
 Maintain ward quite
 Sedatives can be administered to induce sleep

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Investigations
The following investigations are done
1) Random blood sugars
2) Pus swab for culture and sensitivity
3) Blood slide for malaria parasites
4) Urinalysis should be done routinely
5) RFTs and LFTs to rule out renal and liver failure respectively
6) CBC to rule out any infection
7) Hb level to rule out anemia
8) Ultra sound scan to rule out damage to the visceral organs

Complications of burns

Overwhelming infections
Local infections at the burn site can progress to septicemia and secondary infection of a part of
the body.

In spite of the modern antibiotics, the situation can prove rapidly fetal.

Anaemia
This can result from many factors i.e.
 Initial destruction of red blood cell
 Depression of born marrows
 Gastro intestinal bleeding
 Depression of the bone marrows due to the chronic infections

Scars hypertrophy and contractures.

All scars shrink as they mature and extensive burn scars can cause disabling contractures as they
do so movement of joints is limited

Burn keloids
Burns scars often form extensive masses of scar tissue leading to great disfigurement. These are
known as hypertrophy or keloid scars.

They are best presented by expanding healing by the early rafting where necessary and by use
of special elastic pressure garments when healing is complete.

Renal failure
This can be due to the failure to give adequate fluid replacement in time to prevent prolonged
fall in blood pressure.

The renal is the 1st to suffer and once urine secretion ceases, the patient will progress rapidly to
complete renal failure.

This is often irreversible and in spite of renal dialysis, death usually resultsit can also occur due to
blockage of the renal tubular by haemoglobin from blood cells destroyed by the deep burns

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Gastro intestinal bleeding
This occurs quite often as a result to extensive burns. Occasionally the acute duodenal ulcer
develops known as curling ulcer.

Extensive edema
There is always edema at the burnt site and this to some extent accounts for the loss of fluids from
circulation it only begins to re-absorb after 48hrs.

Edema within the upper respiratory tract may obstruct the airway and this demands tracheostomy

Other respiratory problems

Any extensive burn can cause changes in the lungs which leads to venous failure of oxygenation
even where no inhalation burn has occurred
Others include.
 Dehydration
 Shock
 Deep vein thrombosis
 Heart failure
 Asphyxia
 Blindness
 Paralytic ileus

Question 22

a) Define hernia
b) State the different types of hernia
c) List complications of inguinal hernia
d) Describe the pre-operative care of a patient with strangulated inguinal hernia.

Solutions

(a)Hernia is the protrusion of an anatomical structure through the wall that usually contains it.

The wall may be the abdominal wall, muscle fascia, diaphragm or foramen.

b) Types of hernia

Inguinal hernia- is of two types namely

1. Direct hernia-occurs when the organ enters through a weak spot in the floor of Hasselbach‟s
triangle(the area of the lower abdomen above the abdomen-thigh junction)-usually acquired and
associated with heavy lifting, straining, due to constipation, coughing or an enlarged prostate
gland

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2. Indirect inguinal hernia

The hernia contents push through a weak spot in the back wall of the inguinal canal and emerge
beneath the skin.

Results from the failure of embryonic closure of the deep inguinal ring after testis has passed
through it

Femoral hernia

Acquired resulting from herniation through the femoral canal-passage of femoral vessels and
nerves (the canal is wider in women making it more common in females).

 Commonest in middle aged and elderly women

 Rare in children

Inguinal-femoral hernia; Is a form of hernia that is both femoral and inguinal

Umbilical hernia

 Often noted at birth as a protrusion at the belly button (umbilicus).

 It‟s caused when an opening in the abdominal wall which normally closes before birth,
doesn‟t close completely.
 It can develop in obese and in ascitic patients.

Incisional hernia

 Following abdominal surgery, the incision site is a point of weakness.

 It can also be due to poor wound healing at the site.

Epigastric hernia: This is the hernia through the linear alba above the umbilicus usually composed
of fatty tissue and rarely contain intestines.

Diaphragmatic /hiatus hernia: Occurs when the stomach protrudes into the mediastinum through
the esophageal opening in the diaphragm.

Spigelian hernia (hernia spigeli)

 Occurs along the edge of the rectus abdominus muscle through the spigelian fascia, which
is several inches lateral to the middle of the abdomen.
 They are usually small and risk of strangulation.

Obturator/pelvic hernia

 Abdominal contents protrude through the obturator foramen.

 Common in women mostly multiparous and older women who have recently lost a lot of
weight.

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  Pain in the medial thigh, knee and hip (obturator distribution.)

Lumbar hernia: Occurs through the lumbar triangle(the weak area in the posterior part of
abdominal wall.

Sciatic hernia: Herniation of sigmoid colon through the greater sciatic foramen reaching up to the
skin surface and atrophy of gluteal muscles

Cerebral hernia: This is downward displacement of the brain as a result of cerebral oedema,
heamatoma or tumor

Synovial hernia: This is the type of hernia resulting from protrusion of a portion of the synovial
membrane through a tear in the stratum fibrosum of the joint capsule.

Mesocolic hernia; this is a hernia between the layers of the mesoderm.

Labial hernia; the protrusion of the loop of the bowel or other intra-peritoneal organ into labia
majora.

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Complications of hernia

 Strangulation
 Peritonitis
 Intestinal Obstruction
 Urinary retention
 Scrotal haematoma
 Damage to the ileoinguinal nerve
 Ischaemic orchitis
 Hydrocele
 Gangrene of the gut
 Shock

Management of strangulated inguinal hernia

Strangulated inguinal hernia is when the presenting content cannot returned to it‟s site of origin
and the neck of hernia is too tight , blood supply is cut off, and no impulse on coughing, not
reducible, tender and the hernia become gangrenous due to ischemia.

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Preoperative care

This is a form of care that has to be undertaken before a patient is taken to the theatre for any
surgical intervention-herniorrhaphy or herniotomy for this case

General principles of Pre-Operative Nursing Care:

 To render safe administration of anesthesia and to ensure that the patient recovers.
 To prevent or treat circulation failure
 To achieve healing of a wound as quick as possible
 To prevent or treat complications which may occur, and may result from recumbence in
bed.
 To restore rapidly the functional activity of all organs of the body as well as the mind.

Aims:

– To relieve pain
– To allay anxiety
– To prevent shock
– To prevent complications like gangrene.

General Nursing Care:

This is a surgical emergency, the staff nurse calls for help and the medical staff work as a team to
save the patient‟s life.

 Admit the patient immediately in a surgical ward in a warm well laid clean bed.
 The patient is put in a comfortable position with the foot of the bed elevated.
 The doctor is informed immediately.
 A brief history is taken from the patient and relatives.
 The patient and relatives are reassured that everything possible is being done to save the
life of the patient.
 The procedure is explained to the patient and a consent for the operation is signed.
 Continuous vital observations are taken that is ; temperature, pulse, respiration and blood
pressure, results charted and abnormality reported to doctor immediately.
 An I.V line is put up and normal saline 9% alternate with Dextrose 5% is administered to
counteract shock and to correct electrolyte imbalance.
 A strict fluid balance chart is maintained.
 A urinary catheter is passed and left insitu as full bladder makes operation difficult.

The patient is told not to eat anything or drink before the operation, gastric aspiration can be
done as quick as possible to decongest the stomach. The doctor may order for investigation
which include;

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 – Blood for: grouping and cross matching
– Erythrocyte sedimentation rate (ESR)
– Complete blood count (CBC)
– Hb level estimation
 Neuromuscular testing to detect sensory and motor loss of the surrounding muscles.
 Myelography to pinpoint level of herniation
 Emergency ultra sound scan
 Herniography– radiographical examination of hernia after introduction of a contrast
media.

The doctor may order the following drugs;

– IV pethidine 50-100mg stat

– Antibiotics like IV ceftriaxone 1g to prevent secondary infection
– IV atropine 0.6mg to dry the mucus secretion
 The theatre staffs are informed for an emergency preparation.

The patient is prepared physically by:

 Shaving the skin around the site of operation

 Remove artificial wears
 Patient is dressed in theatre gown
 Patient is escorted to theatre with the laboratory results or any other investigation that
might have been done.
 The patient is handed over to theatre staff.
 The nurse comes back and makes a post-operative bed with all the requirements.

Question 23

a) Define thyrotoxicosis.
b) Outline the clinical features of thyrotoxicosis.
c) Differentiate between hyperthyroidism and hypothyroidism.
Solutions

Definition

Is the over activity of the thyroid gland that leads to high levels of thyroid hormone due excessive
production of thyroid hormones in the body causing speeding up of all body functions.

The primary function of the thyroid hormone is to increase the rate of protein, carbohydrates and
fat metabolism in all body tissue so hyper thyroidism affects all major organ systems of the body.

The increase in metabolic and the alteration in the cardiac output, peripheral blood flow, oxygen
consumption and body temperatures are due to increased sympathetic nerve activity.

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Causes

 Grave’s disease: It‟s an autoimmune disease of proteins in the blood that stimulates the
thyroid gland to produce and secrete excess thyroid hormone in blood.

 Thyroditis: Inflammation of the thyroid glands especially subacute painless and sub acute
painful thyroditis which causes release of stored thyroid hormones causing thyrotoxicosis.
 Inflammation and exposure from radioactive substances.

 Over active pituitary gland that stimulates over production of thyroid stimulating
hormone.
 Toxic thyroid nodule (adenoma) an area of abnormal growth within the thyroid gland.
 Neoplasm like toxic multi-nodular goitre
 Chrionic hyperthyroidism; tumors such as chorionic carcinoma embryonal carcinoma and
hydaditiform mole have high concentrations of gonadotrophines that stimulate thyroxine
and tri- iodo- thyroxine.
 Struma ovarii: ovarian tumor made up partly of thyroid tissue that secretes thyroid
hormones.
b) Clinical features

The clinical features are due to the effects of increased thyroid secretion leading to increased
metabolism and sensitivity to simulation of sympathetic nervous system

All body systems are affected

Cardio vascular

 Increased heart rate and systolic hypertension due to increased metabolism

 Palpitation and sleeping pulse of greater than 90b/min and bound in nature
 Cardiac arrhythmias and decreased diastolic pressure
 Increased cardiac output due top increased metabolism
 Cardiac hypertrophy
 Systolic murmurs and atrial fibrillations
Respiratory system

 Increased respiratory rate

 Dysponea on mild exertion G.I.T
 Increased appetite with marked weight loss due top increased metabolic needs
 Diarrhea and vomiting due to over activity of the G.I.T
 Hepatospleenomegally
 Increased peristalsis with increased bowel sounds

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Skin

 Moist and hyperemic (excess of blood in a body part).

 Profuse sweating and cold weather is not preferred to warm sunny day.
 The nails may be thin brittle and detached from the nail bed.
 Hair may be fine silky with marked alopecia (loss of hair).
 Premature graying of hair in men.
 Diaphoresis (excessive sweating) due to increased metabolism.
 Vertiligo (a disorder in which white patches of skin appear on different parts of the body)

Musculo - skeletal system

 Increased activity level despite fatigue and weakness

 Osteoporosis (condition that affects the bones making them weak and fragile)
 A fine tremor of fingers and tongues is present
CNS

 Nervousness, anxiety, restlessness and lack of concentration

 Insomnia (due to hyperexcitment)
 Apathy, weakness, sleepy, confused, withdrawn and depressed especially in the elderly
 Stupor and coma
Eyes

 Difficulty in focusing eyes due reduced muscle function prior to inflammation.

 Increased tearing and irritation due to protrusion of the eyes
 Puffiness around the eyes
 Unusual sensitivity to light.
 Diplopia (double vision) due to loss of eye coordination and focus.
 Eyes are protruding staring and have frightened look. (Exopthalmos)

Reproductive system

 There may be amenorrhea

 Increased libido due to altered levels of gonadotrophines
 Impotence in men
 Gynaecomastia (abnormal enlargement of breasts in men)

C) Differences between hyperthyroidism and hypothyroidism

HYPERTHYROIDISM HYPOTHYROIDISM

Incidence Common in women after child  Common among elderly women

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 birth and menopause

Hormone levels There is an increased level of  There is reduced levels of thyroid

thyroid hormones. hormones
 Raised levels hormones of thyroid
Low levels of thyroid stimulating hormone in blood.
stimulating hormone in blood

Graves disease 
 Hashmoto‟s disease
Thyroid replacement hormone
 Radioactive iodine therapy
Causes Over active pituitary glands  Chronic lack of iodine in diet
 surgery
Exposure and inflammation
from radioactive substances

Increased rate of metabolism

with increased body activities  Decreased metabolism
and function  Reduced body activity
Presentation  Cold skin
Profuse sweating  Low heat rate
Warm moist skin  Weight gain
 Hoarse voice with low speech
Increased heart rate, fine  Constipation
hand tremors  Dull sluggish mentality
 Hair falls out
Loss of weight with increased  Coarse, puffy looks like oedema
appetite but does not pit on pressure

Treatment Drugs like: carbamizole  Hormone replacement therapy

e.g. synthetic thyroxin
Nonmetallic elements likes  digoxine
Iodine

Radioactive isotopes like

radioactive iodine

Beta blocker e.g. propranalol

Complications Thyrotoxicosis crisis/thyroid  Myoxedema coma characterized

storm characterized by fever by reduced respiratory rate,
seizures, reduced blood flow to

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 extreme weakness confusion vital centers, reduced cardiac out
altered consciousness put
irregular heart rate high
pulse rate and shock

Question 24
a) Define a wound.
b) With examples, classify wounds
c) Explain the process of wound healing
d) Mention five common complications of wounds.
Solution
Definition;
A wound refers to impaired tissue integrity. It may also mean a type of skin or mucous membrane
injury in which the skin or mucous membrane is torn, cut, or punctured (open wound) or where blunt
force (trauma) causes contusion (a closed wound) which breaks down its protective function
(moroney 1982).
Or
A wound is the disruption in the normal continuity of bodily structures due to trauma which may be
penetrating or non penetrating (O. James garden, 2005).
Or
A wound is a cut or break in the continuity of any tissue caused by injury or operation (bailliere‟s
nurses dictionary 2nd edition 2005).

Wound classification;
Wounds can be classified by several methods;
These include; according to cause, location, type of injury, wound depth and the degree of
contamination.
ACCORDING TO TYPE OF INJURY;
OPEN
CLOSED
OPEN WOUNDS This involves the breakdown in the protective function of the skin and mucous
membranes. It allows direct loss of blood and tissue fluids from the body.
They include;

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  Incision/incised wounds
 Lacerations/lacerated wounds
 Abrasions/bruised wounds
 Deep wounds
Incision/incised/clean cut wounds
This is a cut in the skin where by the edges are not neat and smooth and are usually caused by
sharp objects such as a knife, blade, broken glass, or scissor. These wounds also tend to bleed as I
case of operations.
Lacerations/lacerated wounds
These are irregular tear-like wounds caused by some blunt trauma eg barbed wire, or claws of
animals like leopards.
Abrasions/bruised wounds
These are superficial wounds in which the top most layer of skin (epidermis is scrapped off due to
sliding fall on a rough surface)
Deep wounds
These are wounds caused by sharp objects capable of penetrating into the body causing damage
to deeper organs of the body e.g.
 Gunshot wounds
 Penetrating wounds
CLOSED WOUNDS
These have no breakdown in the protective function of the skin and mucous membrane and can be
caused by blunt forces such as direct blow, twisting of an organ, sudden strain and bleeding may
take place under the affected tissues. These include mainly contused wounds. E.g
Heamatoma; also known as blood tumor caused by damage to blood vessels that in turn causes
blood to collect under the skin.
Lighting wounds; caused by lightening or thunder, characterized by abnormal heart beat rhythm
and other organ damage.
Blisters: Are swelling under the skin which normally contains serum and may be caused by moist
heat and chemicals.
Classification by the degree of contamination
 Clean wounds
 Contaminated wounds

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  Infected wounds
 Septic wounds
Clean wounds: are usually aseptic and the rate of infection is minimal that is 1-4% and usually
there is no need of antibiotics.
These woundshave clear edges andHealing is usually by first intention examples include: incised
wounds.
Contaminated wounds: the rate of infection is about 5 %-10% here bacteria is present but has
not invaded the tissues. In this antibiotics are needed.
Infected wounds: here bacteria have widely invaded the tissues and they have started
multiplying.
Antibiotics are required to destroy circulating micro-organisms.
Septic wounds: In this, inflammatory reactions have taken place and pus has formed. Antibiotics
are a must. Examples; carbuncles, puerperal sepsis, boils.
Process of wound healing
There are 2 ways in which wounds can heal
 Primary intention
 Secondary intention
First intention
Healing by first intention takes place in closed wounds which have been made under aseptic
conditions eg operation wounds.
There is exudation of plasma, the part dries up and edges come together.
Formation of fibrous tissue helps fill the cut part.
This tissue needs blood vessels to supply blood in the immature fibrous tissue to bring in more
collagen fibers and to dislodge the clot.
Scar formation; the immature fibrous tissue finally becomes scar tissue and the epithelium growing
from the edges of the skin complete the surface scar.
Second intention
Healing by second intention involves granulation and occurs on wounds that have edges which
cannot by brought together and therefore healing from the bottom onwards and takes longer
since it requires epithelization over it.
A great deal of fibrous tissues has to form in order to heal the wound. Here healing is
encouraged by plugging or packing the wounds.

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NB: All the above goes through 3 phases of wound healing.
Inflammation phase:
The cut surfaces become inflamed and blood clot forms and cells debris fill the gap between them
in the first few hours. This happens immediately after an injury.
The body prepares its self by stopping blood loss (Vasoconstriction) to form a blood clot.
This is followed by vasodilatation to increases blood supply which carries different blood cells
that will destroy micro-organisms that might have entered the broken skin.
Cells that play part in this phase are phagocytes and fibroblasts which are brought in by increase
in blood supply of the broken skin.
Phagocytes begin to remove the clot and the cell debris stimulating fibroblast activity.
Fibroblast secrete collagen fibers which begin to bind the surface together.
Proliferative and epithelization:
This is a phase which involves formation of new blood vessels at that site
Fibroblasts continue secreting collagen fibres aiming at filling the gap completely
There is proliferation of epithelial cells across the wound through the clot
The epidermis and dermis meets and grow upwards until the full thickness is restored
Granulation tissue, consisting of new capillary buds, phagocytes and fibroblast develops invading
the clot and restoring the blood supply to the wound.
Fibroblast continue to secrete collagen fibers as the clot and any bacteria are removed by
phagocytosis.
Maturation and remodeling:
The granulation tissues are replaced by fibrous scar tissue. Re-arrangement of collagen fibers
occurs and the strength of the wound increases.
In time the scar becomes less vascular, appearing after a few months as a final line.

The common complications of wounds include;

 Hemorrhage
 Infection
 Shock
 Scar formation
 Dysfunction

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 GENERAL MEDICINE QUESTIONS
Question 25
A four year old child is diagnosed with measles and need your care.
a) What are the five functions of the skin?
b) List the ten signs and symptoms of measles.
c) What nursing care will you give child for the first 72 hours?
d) Mention five complications of measles.
Solution

a) Functions of the skin

 Protection  Give origin to the nails

 Regulate body temperature  Has pores to sweat waste products
 Give colour to a person  Help in production of vitamin D
 Secrete Sebum  Absorption of some drugs
b) Ten signs and symptoms of measles

 Sudden onset of temperature above  Kop lick spots

38.0 degrees  Symptoms worsen on see and third
 Cough day, baby looks miserable.
 Sneezing  4th day macular papular rash starts
 Runny nose at the forehead to behind the ear
 Red eyes and down the trunk and limbs.
 Photophobia  There is desquamation, bronchistasis
 Hoarseness of the voice marked with eyelid that appear
puffy.
 Convulsions
c) Nursing care of measles for the first 72hrs

 Admission pediatric ward  Antibiotics

 Isolation  Nutrition rehab protein and vitamins
 Re assure  Rash apply calamine
 History taking particulars where  Red eyes TEO and vitamin A – 1 1st
disease started, immunization, vitamin day, 2nd dose 2nd day, 3rd dose after
A, nutrition/b – feeding 2wks
 Vital observation  Tepid sponging
 General observation  Tepid sponge
 Inform doctor  Plenty of oral fluids
 Investigation Hb, BS  Oral care GV paint, glycerin of
 Drug asymptomatic borax

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  Honey boosts immunity  Restrict visitors
 Health education  Isolate at home
d) Complications

 Dermatitis  Blindness corneal ulceration

 Pneumonia keratinize, deafness, mastoditis
 Otitis media  Meningitis
 Stomatitis  PEM
 Gastro enteritis  Dehydration
 Laryngeal tracheal bronchitis  Bronhiectasis
(barking cough hoarses)

Question 26
Mrs. Katty 22years old lady has been admitted to your ward with severe asthma.
a) List 7 signs and symptoms of broncho asthma from admission.
b) What management will you give to the patient admitted with severe asthma from
admission until discharge?
c) What complications are likely to occur to this patient?
a) Signs and symptoms of asthma
 Acute onset  Pale and exhausted
 Difficult breathing  Productive cough
 Wheezing expiration  Rapid pulse
 Tightness in the chest  Headache
 Increased respiration  Fever if infection present
 Cyanosis  General malaise
b) What management will you give Mrs. Katty from admission until discharge?

Aims

– To relieve pain – Reassure

– To promote rest – Vital TPR and BP and record
– This is a medical emergency – Loosen tight cloths around chest
– Admission – Inform the doctor
– Sit up position
Immediate treatment

 Nebulize with salbutamol 5mg in 3 – 5mls of saline or give aminophylline 500mgs, IV in

150mls of normal saline in 30minutes then 500mmg in 8hrs in 500mls of 0.9saline.
 Hydrocortisone 100 – 200mgs iv then prednisone 5 – 200mgs bd or tds
 Oxygen 4 – 5liters
 Cough suppressant in the presence of chest infection

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Nursing care

 Give sputum mug

 Continue with vital observations and record
 Plenty of fluids and record on the fluid balance chart
 Diet high protein
 Bladder and bowel care give bed pan when in need
 Cover patient if cold
 Sweep off sweat if present

Symptomatic treatment

 Antibiotics in case of infection e.g. x – pen 1 – 2meg qid

 Pain killer given according to pain from panadol 1gm tds or diclofenac 50 – 70mg tds
 Cough expectorant in the presence of chest infection
 Physiology e.g. breathing exercise
 Psychotherapy re assure continually
 Return for medical treatment
 What to do during an attack
 Remove all gadgets and provide a discharge form

c) List 5 possible complications of asthma

 Emphysema  Bronchitis
 Chronic chest infection  Pneumonia
 Cardiac failure  Pneumothorax
Question 27
There is a lot of peptic ulcer in most of the people around you.
a) Outline five predisposing factors of peptic ulcers you know of.
b) List 7 signs and symptoms of peptic ulcer
c) What management will you give to a patient with peptic ulcers from admission until
discharge?

a) Outline 5 predisposing factors of peptic ulcer disease

 Hereditary  Strong spices

 Gastric hyper secretion  Cigarette smoking
 Drugs like aspirin  Stress
 Alcohol taken with no food

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b) Seven signs and symptoms of peptic ulcer

 Pain which is related to food and  Vomiting

occurs in the epigastrium  Anorexia
 Pain occurring when you come late in  Diarrhea or constipation
the night  Water rush
 Pain occurs when you eat or some 2  Weight loss
hours after eating  Lower chest pain
c) Management of a peptic ulcer from admission until discharge

 Admit to a medical ward

 Bed should be clean
 Position any comfortable position for the patient
 Vital observations

Doctor informed who will order the following;

 Barium meal
 Endoscopy
 Biopsy
 Blood for Hb and blood group
 Drugs cimetidine 200 – 400mg or ranitidine 150mgs tds
 Probatheline 15 – 30mgs daily
 Magnesium tricillate 1gm prn
 OR triple therapy is given of flagyl 200mg – 400mgs daily magnesium triscillate 1gm prn
 OR triple therapy is given of
 Flagyl 200 – 400mgmg
 Omeprazole 150mg bd
 Amoxyl 500mgs tds
 Triple therapy is given for 2 weeks
 Drink fluid that will neutralize the acids e.g. milk
 Health education
 Educate patient to eat in time
 Avoid strong spicy things
 Avoid things that stress the patient
 Have a snack around you during day or night
 Eat small frequent meals

Nursing care

The rest of the care is like any other patient.

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Question 28
What 7 factors can cause a pulse change?
What nursing care will you give to a patient with hypertension from admission until
discharge?
List down any 3 complications of hypertension
Solution

a) List 7 factors that make/cause a pulse change

 Exercises  Drugs
 Fever  Shock
 Emotional conditions  Heart block
 Heat  Posture/position
 Cold
b) Management of hypertension from time of admission until discharge

Aim

 To provide rest
 Reduce blood pressure
 Relieve symptoms and avoid complications
 Admission medical ward
 Bed rest should be clean and the room well ventilated
 Position – any proffered by the patient but sitting up position is encouraged
 Vital observations – temperature, pulse, respiration, are recorded on the chart ½ hourly,
2hrly, 4hrly, and 12hrly when condition improves until discharge
 Bp is recorded more frequently
 Inform doctor
 Reassure the patient
 Investigations
 Blood pressure with good machine
 Palpate vessels for tenderness
 Auscultator the lungs and heart
 Abdominal scan for masses
 Chest x ray
 Urinalysis
 ECG
 Diet low salt diet, avoid fatty foods and high carbohydrates if the patient is obese
 Exercises mild ones are encouraged when BP is fine
 Drugs

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 o Sedatives to relieve anxiety for example diazepam 5mgs nocte
o Diuretics e.g. lasix 40mgs bd
o Hypotensives propranolol 40 – 80 mg b.d or daily
o In critical phase hydralazine or nifedipine is given
 Psychotherapy patient is reassured and anxiety controlled
 Bladder and bowel – fluid balance chart is used to record passed urine and bed pan is
given accordingly
 Health education – avoids any stress, limit or cut out alcohol, reduces weight, treat any
urinary of the thyroid diseases. Take certain drugs groups with caution e.g. corticosteroids
 When blood pressure is controlled patient is discharges with advice on
o When to come for review
o How to take the drugs they have been given
 After has bill has been cleared the patient is escorted to the gate

c) Complications of hypertension

 Congestive cardiac failure

 Chronic renal disease
 Stroke
 Angina pectoris
 Retinal damage

Question 29
You have received a patient at OPD with severe anemia.
a) What are erythrocytes?
b) Mention any 10 signs and symptoms of anemia
c) What management will you give this patient from time of admission until discharge?

a) Definition: These are the red blood cells which are biconcave discs

 They have no nucleus

 Main function is to transport gases mainly oxygen
 They are flexible i.e. they can squeeze through narrow capillaries
 Contain no intracellular organelle
 They are produced by the bone marrow
 Both vitamin B12 and folic acid are required for red blood cell synthesis
 There are approximately 4.5 – 6.5 x 10 to the power of 12 in adults
 Their life span is 120days
 They develop in 7 days
 They develop from the erythropoiesis stem

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b) Mention the signs and symptoms of anemia

 Paleness of the mucus membrane,  Blurred vision

skin, fingers and nail beds  Cyanosis
 Dry skin  Difficulty in breathing
 Dizziness  Oedema of the lower limbs
 Headache  Palpitations
 Drowsiness  Lack of concentration
 General body weakness  Signs of cardiac failure
 Rapid pulse  Anorexia
c) Management of a patient with severe anemia from admission until discharge.

Aims

 To find the treat

 Educate patient on diet
 To treat anemia and prevent complications
 This a medical emergency
 Admission in the medical ward
 Room well ventilated
 Position propped up
 If in shock elevate the foot of the bed
 Provide warmth with a blanket
 Vital observations and record them
 Provide oxygen
 Inform the doctor
 Re – assure the patient
 If the patient is in shock vital observations 1/4hrly, 12hrly until discharge
 Investigations;
 Blood for Hb, malaria, group + cross match
 Stool for ova and cysts
 Patient is prepared for transfusion

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Question 30
It has been identified that many that people have had stroke to many causes.
a) What are three major causes of stroke?
b) Mention 5 differential diagnoses of cardio vascular accident.
c) Describe the nursing management you will give to a person who has sustained stroke
with paraplegia from admission until discharge?

Solution

a) The 3 major causes of stroke are

 Hemorrhage due to rupture of blood vessels in the brain usually artery

 Thrombosis or blood clot forms within the blood vessels which gradually cuts off the supply
to that particular part
 Embolism (clot, air , fat)

b) The 5 differential diagnosis of CVA are

 Encephalitis  Brain tumor

 Migraine  Toxic metabolic disorder
 Hypernatremia  Epilepsy
 Hypoglycemia  Systemic infection
 Meningitis
c) Nursing care you can give a person with stroke and has sustained paraplegias until
discharge.

 Admit on the medical ward

 Position in the recumbent with head turned to one side
 Suction done when necessary
 Insert airway piece
 Do vitals and record
 Re assure patient and relatives
 Inform the doctor
 Pass NGT if unable to feed
 Feed nutritious fluids
 Pass catheter if incontinent
 Investigations e.g. CT scan, blood sugar, b/s for malaria, urinalysis
 Medical treatment
 Given according to the cause e.g. if hypertension hypertensives are given, if
embolism i.e. thrombosis-anti coagulant are given if due to meningo vascular
syphilis a course of a penicillin is given.

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Nursing care

 Maintain iv fluids
 Observe for fits and convulsions and level of consciousness
 Start neurological chart which include response to stimuli, pupil dilatation and respond to
command
 Prevent deformity by doing exercises, proper positioning and supportive appliances e.g.
splints and splints and foot board
 Provide a safe and quite environment and provide rest
 All hygienic measures done until discharge
 Health educate family to accept disability
 Learn to communicate with patient if he has lost speech
 Care of the limb
 Takeoff weight by use of bed cradle
 Position of the paralyzed limbs
 Legs extended with slight flexion
 Small pillow is placed under the ankles to prevent foot drops
 A foot board on a pillow at the end of the bed to prevent foot drops
 Small pillow under the arm to prevent adduction of the arm and to relax muscles
 Passive exercise initially and letter active ones
 Rehabilitation to help patient become independent

Question 31
A patient is brought to your ward unconscious with medical condition
a) List 10 possible medical causes of unconsciousness
b) In details while using a neurological chart explain how you will manage this patient.
c) What 5 complications is this patient likely to get?
a) Ten possible causes of unconsciousness

 Drug poison  Alcohol

 Diabetic coma  Anemia
 Uraemia  Stroke
 Hysteria  Insulin coma
 Epilepsy  Renal failure
 Severe pneumonia  Sleeping sickness
 Cerebral malaria  Syphilis
 Hepatic failure

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b) Managing unconscious patient using a neurological chart

Aims

 Restore patient health

 Prevent complications

This a medical emergency

 Patient is admitted on a medical ward near nurses table for easy observation
 Vital observations are taken ½ hrly when in critical condition and 4hrly in a stable
condition and 12hrly until discharge
 Doctor is informed
 Pass a catheter and nasal gastric tube
 Prepare for investigations
 Assessment
 The level of consciousness is assessed under the following
 Eye opening – patient is called her/his name and because is unconscious is
expected not to open eye
 If unable to open eyes due to pain then he will score 1
 Verbal response – if unable to respond at all will score a zero and if
incomprehensible wards start he will be instructed by the speech therapists until
achievements of normal speech
 Patient limbs are observed for flexion, extension and any motor response that indicates
pain.
 Also patient‟s limbs are assessed for power whether there is mild weakness or
severe weakness or spasmic flexion.
 Eyes
 Are checked regularly whether they are red and unable to, swollen, having any
discharge and how they respond to light
 Investigations
 Urine for urinalysis
 Blood for malaria, Hb, urea, Bilirubin
 Lumber puncture
 Gastric juice for analysis
 Opthalamoscopsy to check for ulcers, bleeding
 Skull X- ray
 General nursing care
 Turing of patients 2hrly and treating pressure areas 4hrly

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  Bed bath once a day and linen cleaned prn
 Fluid diet first then semi solid then solid accordingly
 Orientation and rehabilitation will be done according to the patient‟s condition
 Health education done according to the found disease in the lab
 When patient is better is advised and sent home

c) Possible complications of unconsciousness are

 Respiratory obstruction  Brain damage

 Hypostatic and pneumonia  Mental retardation
 Deep vein thrombosis  Aphasia
 Paralysis  Ataxia
 UTI – cystitis and pyelitis  Corneal ulceration
 Renal calculi  Bed sores

Question 32

a) Describe the cycle of respiration

b) List 7 predisposing factors of tuberculosis
c) In details what health education will give to a patient admitted for the first time with
tuberculosis

Solution

a) The breathing cycle consists of

The average respiratory rate is 12 to 15 breaths per minute. Each breath consists of 3 phases

 Inspiration
 Expiration
 Pause

The visceral pleura is adherent to the lungs and the pariental pleura to the inner wall of the
thorax and to the diaphragm. Between them is a thin film of serous fluid

Inspiration

When the capacity of the thoracic is increased by simultaneous contraction of the intercoastal
muscles and diaphragm. This reduces the pressure in the pleural cavity to a level considerably
lower than the atmospheric pressure.

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The visceral pleura follow the pariental pleura pulling the lung with it. This expands the lungs and
the pressure within the alveoli and in the air passages falls drawing air in to the lungs in attempt
to equalize the atmospheric and alveolar air pressures.

The process of inspiration is active as it needs energy for muscle contraction. The negative
pressure created in the thoracic cavity aids venous return to the heart and is known as the
respiratory pump

At rest, inspiration last about 2 seconds

Expiration

Relaxation of the intercostal muscles and the diaphragm results in downward and inward
movement of the ribcage and elastic recoil of the lungs.

As this occurs, pressure inside the lungs exceeds that in the atmosphere and so air is expelled from
the respiratory tract.

The lungs still contain some air and are prevented from complete collapse by the intact pleura.
This process is passive as it does not require the expenditure of energy.

At rest expiration lasts about 3 seconds and after expiration there is a pause before the next
cycle begins

b) The 7 predisposing factors of TB are;

 Poor health and malnutrition  Over crowding

 Age  Poorly lit houses
 Un immunized children  High rate of TB in the population
 Frequent exposure to TB patients  Inadequate medical care
 Dusty environment  Low immunity
c) Health education given to a patient diagnosed with TB for the first time

Introduction

 Seat this person

 Re assure
 Explain to him what TB is and how contagious its is
 Its signs
 And how the investigations has confirmed that he has TB

Drugs

 You will take drugs for the next 8 months

 Drugs are to be taken every day without missing

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  You have to have a particular time to take these drugs
 You have to take it after taking food
 You may get these problems while on these drugs
 You have to take it after taking food
 You may get these problems while on these drugs namely nausea, vomiting, itchy skin, skin
rash, dizziness, general malaise
 When you fail to comply it will lead to stronger drugs (injections for 2 months)
 When you get worse with drug side effects report immediately to the hospital
 You will receive drugs monthly then you come for another batch

Hygiene

 Use a sputum mug for spitting

 Clean bed linen prn
 Hold on the mouth while coughing
 Do come too close to other family members
 Windows should be left open unless too much coughing

Diet

 Eat a well-balanced diet

 Eat on time
 You may lose more weight but after a while you will gain wait
 Do not do strenuous work in this acute phase

Question 33
A patient is brought to your ward unconscious with a medical condition
List ten possible causes of unconsciousness
In details while using a neurological chart, explain how you will manage this patient.
What 5 complications is this patient likely to get?
Solution

PART A

There are various causes of unconsciousness which include;

 Cerebral vascular accident [stroke]

 Alcohol intoxication leading to alcoholic coma
 Diabetic keto acidosis[diabetic coma]
 Hypoglycemia
 Hepatic encephalopathy due to hepatic failure
 Meningitis

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  Cerebral or complicated malaria
 Encephalitis
 Shock[this can either be oligaemic, neurogenic, anaphylactic or septic shock]
 Drug overdose like narcotics
 Electrolyte imbalance like hypokalaemia and hyponatraemia.
 Hypoxia

PART B

Aims of management

– Careful and intelligent observation to detect early onset of any significant change in the
condition.
– Preservation of life and prevention of complications while the patient is unconscious.
– Rehabilitation of conscious patient to maintain health.
– To identify the underlying cause

Management

Unconsciousness is a medical emergency, therefore health workers need to work as a team and
fast so as to save the life of the patient

Admission

The patient is admitted on a medical ward in an intensive care unit, in a well made admission bed
with bed rails and the following apparatus;

Footrest, small mackintosh and towel at the top of the bed with a suction machine and oxygen
concentrator at the bed side.

Position;

The patient is put in the left lateral position to minimize damage to the lung tissue and aspiration

Assessment of the patient; this involves

History taking

Brief history is taken which includes biographic data that is to say name, sex, age, address, and
next of kin. Past medical history, the relatives are asked if the patient has previously suffered
from any medical condition such as malaria, meningitis, or diabetes mellitus, this will help in
tracing the cause. Past surgical history, care takers are asked if the patient has ever gone through
any surgery or blood transfusion. Social and family history, relatives are asked about the
presence of chronic illnesses such as hypertension, diabetes mellitus in their family and also if the
patient drinks alcohol or has been stressed days back.

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Vital observations;

These are taken and recorded which include

Temperature ;pyrexia or hyper pyrexia should be reported at once because it denotes infection
and damage to the heat regulating centers

Treatment – exposing the patient, tepid sponging and if it persists, antipyretics peracetamol
[rectal] are administered.

Pulse rate and blood pressure;tarchycardia and hypotension should be reported immediately as
they denote raising intra cranial pressure and cerebral hemorrhage

Treatment- intravenous fluids such as normal saline or ringers lactate is administered through and
intravenous cannula.

Respirations; shallow and rapid respirations or slow and stetorous respirations denote increased
intracranial pressure and must be reported at once.

Maintenance of airway, breathing, and circulation;

Airway-

This is maintained by proper positioning of the patient, suction of excess secretions, and insertion
of an airway piece so as to keep the airway patent.

Breathing-

Ascertain if respirations are present, monitor oxygen saturations and if below 90%, administer
oxygen preferably 5-6 litres for an adult, continue monitoring the patient using an oximeter.

Circulation-

Check the patient‟s pulse and blood pressure, pallor of the mucous membranes, palms and also
the capillary refill. Incase of any deviation from normal, administer warm normal saline.

General examination of the patient;

The patient is examined from head to toe for signs of jaundice, anaemia, cyanosis, oedema,
lympadenopathy, dehydration and signs of shock like cold clammy skin, pallor of the mucous
membrane, rapid shallow breaths.

Breath of the patient, if alcoholic then it indicates alcoholic intoxication, if sweet smell it indicates
diabetic comma.

Examine the limbs for injury, weakness or paralysis.

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The doctor is informed about the patient, who will re examine and re assess the patient and
orders for the following procedures and investigations.

Procedure

 Accessing an intravenous line for fluid resuscitation and drug administration.

 Insertion of a urinary catheter which will help in fluid balancing, monitoring of renal
function and keeping the patients bed dry and tidy.
 Insertion of a naso gastric tube aspiration of gastric contents and later feeding.

Investigations

These include laboratory and radiological investigations.

1. Laboratory investigations include both haematological and chemistry.

Haematological;

Blood taken off for malaria parasites to rule out malaria, haemoglobin levels are checked to rule
out anaemia, grouping and cross match in case haemoglobin level is less than5g/dl, erythrocyte
segmentation rate, and white blood cell count total and differential to rule out infections.

Chemistry;

 Serum ammonia levels, blood urea and nitrogen and electrolytes like sodium, potassium,
magnesium and calcium are assessed to monitor the functioning state of the kidneys.
 Arterial blood gases like oxygen and carbondioxide are assessed to rule out hypoxia.
 Liver functioning tests are done to assess the functioning state of the liver. These include
aspertate amino transferase (AST), alanine amino transferase (ALT).
 Blood Ph, if acidic indicates metabolic acidosis.
 Lumber puncture is done to obtain CSF for analysis to rule out meningitis.
 Random blood sugar to rule out hyper or hypoglycemia.

2. Radiological investigations include magnetic resonance imaging, computer tomography scan

electro encephalogram to visualize and determine the state of the brain. Kidney scan to
determine the state of the kidneys.

Neurological assessment

This ordered by the doctor and the following are assessed for and recorded on a neurological
chart.

i. Vital observations, temperature, pulse, respirations and blood pressure are done and
recorded on the chart hourly.

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 ii. Pupil reaction, with the help of a torch as a source of light, pupil reaction is noted. This can
either be constriction or dilatation and the score ranges from 1 to 8mm with 1 being the
best score
iii. Constriction or dilatation of the pupil can either be bi or uni lateral.
iv. Glasgow coma scale; this scored out of 15 and is used to assess the level of consciousness.

The parameters are;

Eye response
Eyes open spontaneously-4
Eyes open to verbal response-3
Eyes open to pain-2
No eye response-1
Verbal response
Oriented-5
Confused-4
Inappropriate words-3
Incomprehensible sound-2
No verbal response-1
Motor response
Obeys command-6
Localizes pain-5
Withdraws from pain-4
Flexion to pain-3
Extension to pain-2
No motor response-1

If the score is less than 8, neurological assessment is done continuously hourly.

However, if the score is 10 and above, then assessment is done 6 hourly

Treatment/medication

This is prescribed by the doctor as per investigation results or underlying cause.

Drug overdose; if is the cause, a specific antidote for the drug is given to counter act its adverse
effects. Example, naloxone is given incase of narcotic over dose.

If in shock;

Hypovolaemic- fluid replacement is done intravenously with normal saline or ringer‟s lactate.

If anaphylactic shock, then; hydrocortisone IV 200mg stat and then as per progress.

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If septic shock, broad spectrum antibiotics are administered to treat the infections.

Hypoglycemia is managed by giving dextrose 25% 2 mls/kg body weight bolus to raise the
glucose levels followed by dextrose 5% 500 mls maintenance and later, the random blood sugar
is repeated.

Electrolyte imbalance is managed by administration of intravenous fluids- Ringer‟s lactate,

potassium chloride, and magnesium sulphate as per deficient electrolytes.

Nursing care

Airway maintenance;

This should be observed and is achieved by loosening tight clothes around the neck, suction
whenever necessary and proper positioning- left lateral.

Patient turning and care of pressure areas:-

2 hourly turning of patient is done so as to prevent spillage of secretions into the other lung.

Care of pressure areas is done 4 hourly by circular massaging with the help of soap and
Vaseline. This helps to stimulate circulation and improve on the patient‟s health.

Diet/feeding;

Is so vital so as to enable the body‟s metabolic activity although one is unconscious.

The patient is initially fed parentally with Iv fluids and if the state of unconsciousness persists, then
feeding via a naso gastric tube is commenced 3 hourly with light nutritious diet first, then semi
solid foods and later a normal diet initiated with all food nutrients ,i.e.; vitamins, carbohydrates
and proteins. Aspiration should always be done before feeding to determine the rate of
absorption. Flash the tube with 20 mls of normal saline before and after feeding.

Hygiene

This is carried out so as to maintain the patient‟s integrity.

Eye care is done daily and in case of any infection, tetracycline ointment is applied. Eyes are
protected with eye shields so as to prevent damage and drying of the cornea.

Oral care is done 3 times a day to maintain a good odour and stimulate salivation.

Bed bath; the patient is helped with bathing since he cannot help himself. As his condition
improves, assisted bathing is done and later self aid.

The bed should always be well made with clean linen and in case of incontinence of urine or
faeces, pampers and urinary catheters are of great help.

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Bowel and bladder;

Bladder- since the patient usually presents with incontinence, catheterization under a septic
technique is done and a fluid balance chart started.

Patient is observed if passing stool and if constipated, an enema is given.

Exercises;

Are both active and passive.

Initially, passive exercises like massaging the chest limb movements and patient‟s turning is done-
these help prevent contractures and stimulate the blood circulation.

Later as the patient improves, active exercises are done and the patient is encouraged to support
self, move out of bed and involve self in his/her care.

These are done by both nurses and physiotherapists.

Psychotherapy:

Is commenced as the condition improves.

He or she oriented of the place, time and people around.

 Pain management is initiated since at this the patient will have started feeling pain.
Diclofenac 75 mg intra muscular stat if the pain is severe and later mild analgesics like
paracetamol 1 g if no contra indications.
 Patient‟s position is changed and the patient can assume a sitting up position with the
support of a back rest and pillows.
 Diet: if the patient can tolerate feeds and the absorption rate is good, the naso gastric
tube is removed and the patient starts feeding orally with small quantities of feeds as
tolerated by the patient and later increased.
 Bladder training is done 2 days prior to removal of catheter by spigoting the catheter
and later removed.
 Oral hydration is commenced after counter acting dehydration and if the patient can take
orally, intravenous cannula is removed and resuscitation is done per oral.

Health education;

This is as per the cause of unconsciousness

 If infections like meningitis or malaria was the cause, patient is educated about early
treatment of infection, and drug compliance.
 For alcohol intoxication, he or she is taught the dangers of alcohol abuse and advised to
reduce on alcohol intake and if possible stop.

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  Patient is educated about the proper use of insulin at the right time and the right doses if
it is found out that diabetic coma was the cause of unconsciousness.
 In case of hypoglycemia, patient is advised about proper taking of meals, avoid strenuous
exercises when hungry and control of stress.

Preparation for discharge;

When the patient‟s condition is satisfactorily good, he and the relatives are informed about
discharge, encouraged to clear hospital bills and return the hospital property if any

Patient‟s property that was put in custody is also returned.

Discharge and advice on discharge;

Patient is advised to comply on all medication as given, advised to change his or her life style
and given signs that need immediate return to hospital like; persistent headache and dizziness,
blurred vision, jaundice or persistent vomiting and signs of hypo or hyperglycemia like reduced
concentration, increased sweating.

He or she is given a review date and advised to come back

He is discharged and wished a safe journey and complete recovery.

1. Pneumonia [hypostatic]; this is as a result of aspiration and inadequate chest

exercises.
2. Deep venous thrombosis; this is due to poor nursing care especially if passive and
active limb exercises we not carried out
3. Paralysis as a result of damage of some part of the brain cells due to prolonged
hypoxia and electrolyte imbalance
4. Pressure ulcers; these come as a result of poor nursing care especially if care of
pressure areas and regular turning was not done
5. Mental retardation /permanent brain damage due to prolonged blood and
oxygen supply to the brain especially in stoke and shock
6. Urinary tract infections as a result of poor hygiene and catheter care or failure to
maintain aseptic technique during the procedures

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Question 34
A 4years old child is diagnosed with measles and need your care.
a) What are the five functions of the Skin.
b) List the ten signs and symptoms of measles.
c) What nursing care will you give child for the first 72hours.
d) Mention five complications of measles.

Solutions

The skin is an organ system that regulates the body temperature ,protect the internal structure,
senses, stimuli, provides a shield from the sun`s harmful effect and it`s the largest organ of the
body which account for about 12 to 15 percent of the weight and cover1.5 to 2m2 of the surface
area.

FUNCTIONS OF THE SKIN

THERMOREGULATION OF THE BODY TEMPERATURE

When the environmental temperature is high or low,body the temperature remains constant within
the homeostatic limits. Heat is dissipated (given out) when temperature are high by dilation of the
dermal blood vessel and conserve in cold environment by their vasoconstriction.

EXCRETION

Limited amount of nitrogen containing waste are eliminated and sodium chloride is also lost.

CUTANEOUS SENSATION

The skin provides {seat} for cutaneous sensory receptor which provides us with information about
external environment i.e it`s temperature ,texture, and pressure exerted by objects.

PROTECTIONS

It`s put up three barrier,

Chemical barrier

This includes skin secretion and melanin, although skin surface has bacteria, the acidity of the skin
secretion retards their multiplication.

Sebum also killed bacteria and melanins are chemical pigment shields from ultraviolent light.

Physical barrier

This is provided by its continuity and the hardest of the keratinized cells.

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Biological barrier

This includes langhern`s cell of the epidermis and phagocytic cells in the dermis.

VITAMIN D SYNTHESIS

When modified cholesterol molecules in the epidermis cells are mediated by ultraviolent light,
they are converted to vitamin D which is then absorb into the dermal capillaries and are
transported to other areas to play a role in calcium metabolism.

BLOOD RESERVOIR

Skin vascular supply is extensive and can hold large volume of blood. When others body organs
needs greater blood supply e.g in exercise, dermal blood vessel are constricted and blood is
directed to the general circulation making its available to muscle and other organs.

– Formation of new cells from stratum germanium to repair minor injuries.

– Storage of water, fats, glucose and vitamin D.
– Maintenance of the body form.

SIGNS AND SYMPTOMS OF MEASLES

Measles is an acute viral infectious disease of the respiratory tract commonly affecting children
caused by measles virus.

The signs and symptom occur in stages and these includes;

– Incubation stages
– Prodromal/pre-eruptive stage
– Catarrhal/ eruptive stage
– Convalescence/ Recovery stage

Incubation period/stage

Generally it last from 10-14days, here the patient may not have any signs and symptoms.

Prodromal /pre-eruptive stage.

During this stage signs and symptoms appears, its abrupt onset but mild to moderate s/s
characterized by;

– Fever
– Headache
– General malaise
– Anorexia
– Enlarged neck glands
– Abdominal pain

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 – Diarrhea
– Vomiting

Catarrhal/eruptive stage

It’s an abrupt onset with severe s/s which includes;

– Common cold (Coryz), very high fever

– Cough
– Photophobia
– Red eye ,Conjunctivitis.
– Hoarseness of the voice

Koplik spots

Its distinct feature of measles. Koplik spot are small white spots on the mucous membrane of the
mouth beside the molar teeth which often disappear when the rash appears.

The temperature rises on the first day (37.8-39.4), it usually fall slightly on the third day, to rise
again on the 4th day with the onset of rash.

The rash appears around the 4th day of the illness and is seen first on the fore head, behind the
ear ,neck and later spreads all over the face and the whole body. The rash is described as a red
maculopapular eruption which gives a bloated, swollen appearance to the face.

Convalescence /recovery stage

This is stage when the sign s and symptoms of the disease begin to disappear and the patient`s
condition start to improve. This stage is characterized by the following features;

– Desquamation of the skin

– Falls in the body temperature
– Hoarseness of the voice disappear
– Patient gains weight

NURSING CARE /MANAGEMENTS GIVEN TO THE PATIENT WITHIN 72HOURS

Aims of care/mgt

– To reduce body temperature

– To correct the dehydration
– To prevents further complications.

Admission

The child is admitted in children`s ward in an isolation units in well ventilated room and moderate
light.

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Recording of patient`s particular on the admission forms which includes names, age, next of kin
and full address.

Reassurance of the mother/care giver about the child‟s condition.

Observations

Vital observation which includes temperature, pulse, respiration, blood pressure and weight of the
child and record it in observation chart which is going to act as baseline observation for
monitoring the patient condition.

General observation should also be carried out from head to toe to identify any abnormality like
jaundice ,edema. Dehydration, cyanosis, anemia, and lymphdenopathy. And record them in
patient file.

Inform the doctor about the patient meanwhile prepares for what the doctor is going to use,
She/he is going to do comprehensive assessments and ordered for investigations and medical
treatments.

NOTE; Remember to carry out any procedures depending on the patient`s finding like, Tepid
sponging incase of high fever.

Investigations

There is no specific investigations done to confirm the disease BUT investigation may be done to
rule out others diseases like;

Blood for;

Blood slide for malaria parasites

FBC- To rule out others infections

Urine- For urinalysis.

Saliva- Salivary measle specific IgA testing (but rare).

Medical Treatments

There is no specific treatment for measles, It`s treated symptomatically. The followings drugs may
be prescribed;

Antibiotics, (to treat underlying infection).

Cephalexin syrup 125mg 12hrly for 1 week (children below one year) 125mg 8hrly for 1week
(1-5year).OR Amoxyl syrup 125mg/5mls 8hrly for 1 week.

In severe case injection ceftriaxone I.V 50-100mg/kg body weight once a day for 5 days

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Tetracycline eye ointment apply 8hrly.

Analgesics (to reduce the temperature).

Syrup cetamol 125mg 6hrly for three day.

Antihistamines (to reduce itching)

Calamine lotion apply 12hrly.

Vitamins

Vitamins A capsules 100,000IU orally o.d for 2days (children below 1year) to prevent eye
complication as a result of vitamin A deficiency.

Grovit drops 2-3 drops daily for 1week /syrup multivitamin 5ml 12hrly for a week to improve on
the patient`s appetite.

Intravenous fluids incase of severe dehydration due to diarrhea and vomiting or low intake.

Cough mixture like cough linctus or Brozedex to soothe the patient`s cough.

Diet

The patient is given plenty of oral fluids to replace lost fluids through vomiting and diarrhea,
easily digestible foods rich in vitamins and proteins is also given to promote quick recovery.

– Encourage the child to take frequent small meal.

– A nasal gastric tube can be passed for feeding to patient who are unable to eat or drink.
– In case the child is very dehydrated, then I.V fluids are put up to replace the lost fluids
and fluid balance chart should be maintain.

Care of the skin

Padding of the fingers to avoid the child from over scratching of the skin.

Apply calamine lotion as prescribed to relieve itching of the skin.

Care of the mouth and eyes

Mouth, Oral hygiene emphasized, frequent mouth care with warm saline, keep nostril clean and
area around the NGT kept clean and dry. Apply gentian violent 1% in the moth ulcer.

In case of dry lips apply glycerin borax to lubricate the lip to avoid cracking.

Eyes, Eyes cleaned with warm saline, to avoid rubbing of the eyes , apply a TEO ointment.

In case of one side of the eye is affected; the child should be lie on the affected side to avoid
infecting the other.

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Direct sun light on the eye should be avoided.

Hygiene

– Patient should be given a daily bath, bedding changed frequently.

– For discharging ears, the child should lie on the affected side for easily drainage, keep
external area of the ear clean and dry.
– Ear wicking is encouraged and appropriate antibiotics administered.
– Disinfection of used soiled linen and utensils.
– Used swabs, discharges, or secretions from the noise, eyes, ears ,throat, should be
properly disposed off and burnt.

Bed rest

– Visitor should be restricted and only allowed during the visiting hour, radio and TV should
be maintained at low volume to enable patient have enough rest.
– Dim light should be encouraged because of photophobia and nurses, doctor and
attendant should be encouraged to minimize voice.

Sleep

– Patient should be allowed to have enough sleep; this is achieved by switching off light in
time and restricting noise in the ward.

Observations

– Continue observing the general condition of the patient and take note of any derivation
from the normal. Take vital observation at least 2-4hrly, T,P,R and record them in vital
observation chart.
– If the temperature is very high do tepid sponging, gives cold drink and apply cold
compress on the fore head to reduce the temperature.

Bowel and Bladder care

– Bowel, child may have diarrhea or constipation, so all these should be observed for and
treated accordingly.
– Bladder, due to high temperature and dehydration which is usually a x-tics of measles ,the
child may not pass urine. This should be observed for.

Exercises

– Encourage patient to do both active and passive exercises especially deep breathing
exercise by giving balloon to blow to prevent complications.
– He/she is also encouraged to moves about in bed and playing objects like toys are given
to stimulate the child`s mind.

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Health education

– Health educates the mother/ care taker on the mode of spread, signs and symptoms and
preventions.

COMPLICATIONS OF MEASLES

– Pneumonia due to invasion of micro-organism in the lungs

– Acute Laryngo-Tracheo-Bronchitis (LTB)
– Otitis media due to infection from Eustachian tube to the middle ear and may lead to
deafness.
– Conjunctivitis
– Corneal ulceration which may lead to blindness
– Encephalitis
– Acute gastroenteritis.
– Malnutrition,(PEM)-Kwashiorkor and marasmus.
– Sub acute sclerosing panecephalitis.

Question 35

It has been identified that many people have had stroke due to many causes.

a) What are the major causes of stroke?

b) Mention five different of cardiovascular Accidents.
c) Describe the nursing care you will give to a person who has sustained stroke with
paraplegia from admission until discharge.

Solution

a) Definition.

Stroke also known as Cerebrovascular accident (CVA), or Cerebrovascular Insult(CVI), or Brain

attack is defined as; the death of the brain tissue (cerebral infarction) due to lack of blood flow
and insufficient oxygen to the brain.

Types of stroke

There are two types namely;

(1) Ischemic stroke-due to lack of blood supply to the brain.

(2) Hemorrhagic stroke- due to rupture of the weakened blood vessels of the brain.

Causes of stroke

There are three major causes of stroke namely;

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 (1) Cerebral thrombosis, especially in elderly people e.g. in arterosclerosis where the
cerebral arteries are thickened, and roughened blocking blood flow hence forming clots
(thrombi) depriving the brain of its blood supply, and therefore resulting into tissue death.
(2) Cerebral embolism, an embolus or a detached clot may lodge in one of the cerebral
arteries and produce a stroke. Some diseases especially those affecting the left side of
the heart cause formation of blood clots or emboli e.g. Mitral stenosis with atrial
fibrillation, Myocardial infarction, Subacute bacterial endocarditis, etc.
(3) Cerebral haemorrhage, rupture of weakened cerebral blood vessels producing
haemorrage into the brain especially in hypertention, DM, lesions etc.

Predisposing factors to stroke

 Chronic diseases like HT, DM, M.I e.t.c.

 Severe accidents like RTAs involving fractures
 Pulmonary embolism
 DVT
 Obesity
 Smoking
 Alcohol consumption
 Blood disorders like leukemia, anaemia etc.
 Arteriosclerosis
 Pts on IV therapy, and BT
 Pts who undergo major operations
 Drugs like coagulants, Ococs etc.

a)To make a diagnosis of cerebral vascular accident, the doctor carries out the following,

Physical examination, and this includes taking medical H/O, and a neurological status helps giving
an evaluation of the location and severity of the stroke.

(1) CT, and MRI scan to R/O whether a hemorrhage or a brain tumor caused the stroke. They
also confirm the stroke.
(2) Electrocardiogram to R/O abnormal heart rhythms, irregular heartbeats can cause
formation of new blood clots that can cause another stroke.
(3) CBC to R/O deficiency of RBCs (anaemia), an excess of RBCs (polycythemia), a cancer of
the WBCs (leukemia), or infection, Platelet count, etc.
(4) CSF analysis to R/O ICP, infection

b)Nursing care of a patient who has sustained a stroke with paraplegia from admission until
discharge.

Paraplegia is paralysis of the lower extremities, and the lower trunk.

This is a medical emergency, and therefore requires urgent attention from the nursing department.

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Aims

o To restore the normal brain function.

o To dissolve the clots, or treat the cause of the stroke
o To prevent complications
(a) Admission-The patient is admitted in the intensive care unit in the medical ward near the
nurses room for close monitoring and proper management of the patient.
(b) Position-Slowly, gently lift and put the patient in the most comfortable position possible
while supporting the patient‟s lower trunk and extremities.
(c) Quickly ensure that the ABCs of life are properly managed, i.e. ensure that the airway is
clear by removing all clothes of constrictive nature around the airway, ensure that the
patient is breathing normally, and ensure that the blood is circulating around the patient‟s
body.
(d) Assessment-Take a brief and quick history of the patient‟s condition from either the
patient if conscious and able to talk, or from relatives.
(e) Observations-Vital Observations especially TPR and BP are taken and recorded on the
vital observation chart.
(f) Specific observations e.g. Dyspnoea, anaemia, cyanosis, level of consciousness using a
GCS, SPO2, Oedema
(g) General condition-i.e. whether the patient looks generally ill.
(h) The Glasgow coma scale (GCS) for assessing the level of consciousness.

Observation Response score

Eye opening  Spontaneously 4
 To speech 3
 To pain 2
 No eye opening 1

Best verbal response  Oriented 5

 Confused 4
 Inappropriate 3
 Incomprehensible 2
 No verbal response 1
Best motor response  Obeys command 6
 Localizes pain 5
 Withdrawal from pain 4
 Flexion to pain 3
 Extension to pain 2
 No motor response 1
Total 3-15

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a) Investigations, they include:

Physical examination

o CT, and MRI scan

o Electrocardiogram
o CBC
o CSF analysi
o These are done to confirm the stroke.

b) Medical Rx.-meanwhile waiting for results, the Dr prescribes the following drugs;

o Tabs Digoxin 0.25mgs-1mg O.d to lower the heart rate if it‟s too fast
o Administer humidified oxygen using a face mask if the SPO2 is less than 90%
o Tabs Aspirin 300-900mgs t.d.s x 3/7, to relieve pain and also break clots if any.
o Anticoagulants e.g. IV bolus Heparin 5000 I.U stat then continue with 250 I.U/kg b.d x
5/7 plus Warfarin 5mgs single dose in the evening starting on day 3, After day 3,
maintenance dose of 2.5mgs-7.5mgs O.d daily to dissolve the clot. Incase of any reaction
to heparin, the Dr prescribes I.V Protamine (antidote to heparin) 50mgs slowing for 10
minutes. But if there is any reaction to Warfarin, give 2-5mgs of Vitamin K subcutaneously
as an antidote.
o If these anticoagulants fail, then do thrombectomy
o If the patient‟s B.P exceeds 140/90mmHg, or if the patient has H/O HT, the Dr prescribes
antihypertensive for the patient.

c) Specific Nursing care-These includes the care of the paralyzed limbs

Care of the paralyzed limbs

 All weights must be taken off the paralyzed limbs

 Exercises-Passive movements several times a day from the time of admission should be
started to prevent arthritis, Joint fixation, DVT, hypostatic pneumonia, pressure sores.
Reassure and encourage the patient to walk if able or help patient walk using a Zimmer
walking frame or a 4 legged stick.
 Position-The paralyzed limb should be placed in the best comfortable position to prevent
or minimize deformities. The paralyzed limbs should be prevented from rotating outwards
by proper use of sandbags or firm pillows. The leg should be in a position of extension
with the knee slightly flexed to relax the muscles, this is done by placing a small pad or
pillow under a joint below the knee. A foot board or pillow should be placed at one end
of the bed to prevent foot drop.
 Pressure areas. Paralyzed patients are very liable to developing pressure sores if not
properly nursed. Therefore, preventive measures such as placing a small flat pillow under
the ankle, frequent turning of the patient, caring for the skin such as bed bath and
keeping it dry.

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  Care of the bladder-urine incontinence or retention may be present, therefore, an
indwelling catheter may be passed under aseptic techniques with a closed drainage bag
attached to it.
 Care of the mouth-done 4 hourly until the patient‟s condition improves
 Psychological care-continuous reassurance is considered.
 Care of the bowel-an enema may be passed
 Diet-Nutrition and fluids may be given IV or through an NGT, later if the patient is able to
take feeds orally, light soft nourishing diet is given.

Occupational therapy-the therapist prepares the patient for various day to day activities on
returning home, climbing of stairs, using the bath etc

Discharge from hospital-If the patient‟s condition has improved as evidenced by good SPO2
above 90%, dissolution of the clots, normal heart rate, the Dr then considers discharge of the
patient on drugs and advice is given, IV lines, NGT, Catheter, Sandbags are removed, .

Advice on discharge

 If the patient smokes, counsel the patient to stop.

 Educate the patient to restrict salt intake.
 Always take the prescribed drugs
 Come back for review on the appointed date but in case of any problem before the
appointed date, the patient is advised to come back.
 Regularly check BP

Question 36

Mr. Ogwang is admitted to a medical ward with acute cholecystitis as a provisional

diagnosis.
a) With the aid of a well labelled diagram describe bile formation.
b) Explain the different types of jaundice.
c) Explain the management of Mr. Ogwang’s condition until discharge.
d) List complication of cholecystitis.
Solution

Bile is a dark green alkaline digestive juice secreted by the liver and stored in the gallbladder. It
consists of:

 Water {88%}  Bile salt

 Mineral salts  Bile pigment
 Mucus  Cholesterol

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Bile is formed is formed in the liver cells called hepatocytes. The hepatocytes synthesize the
constituents of bile from the mixed arterial and venous blood in the sinusoids. These include bile
salt, bile pigment and cholesterol. The liver manufactures about 6ooml to 1 liter of bile per day.

Bile formed in the hepatocytes drains into the bile canaliculi.The canaliculi.This join up to form
larger bile canals until eventually they form the right and left hepatic ducts which drain bile from
the liver.

As bile travels down the ducts, the linings of these passages secrete water sodium and
bicarbonate ions into the bile there by diluting it. These additional substances.

Helps to neutralize stomach acid which enters the duodenum with partially digested food [chyme]
from the stomach.

Most of the bile produced by the liver is stored in the gallbladder.This hollow organ can only
hold 30 to 60mlsof bile and is able io store the large quantity of bile like bile salts, cholesterol
lecithin and bilirubin stays in the gallbladder.

Question 37

Mr. Ogwang is admitted to a medical ward with acute cholecystitis as a provisional

diagnosis.
a) With the aid of a well labeled diagram describe bile formation.
b) Explain the different types of jaundice.
c) Explain the management of Mr. Ogwang’s condition until discharge.
d) List possible complications of cholecystitis
Solutions

(b) Jaundice is a yellow discoloration of the skin and mucus membrane due to an increase in the
circulating amount of bilirubin in blood.

Jaundice is a sign of abnormal bilirubin metabolism and excretion. Bilirubin is produced from the
breakdown of haemoglobin usually conjugated in the liver and excreted in the bile.

Conjugation is the process of adding certain groups to bilirubin molecule in order to make it water
soluble and greatly enhance it‟s removal from blood (excretion of bilirubin).

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Un conjugated bilirubin ( fat soluble) has a toxic effect on brain cell, however it‟s unable to cross
the blood brain barrier until the plasma level rises above 340umol/L , in case it does so, may
cause neurological damage, seizures( fits) and mental impairment.

Before the yellow coloration of jaundice is evidenced, serum bilirubin may rise to 40-50umol/L
(normal bilirubin level is 3-13umol/L).

Causes of jaundice

Excess haemolysis of red blood cells with the production of more bilirubin than the liver can deal
with.

Abnormal liver function that may cause:

– Ineffective conjugation of bilirubin.

– Interference with bilirubin secretion into the bile
– Incomplete uptake of un conjugated bilirubin by hepatocytes.

Obstruction to the flow of bile from the liver to the duodenum.

Inadequate albumin which binds bilirubin and enables it‟s transportation to the liver for
conjugation.

Drugs like cephalosporin eg Ceftriaxone.

Types of jaundice

Haemolytic jaundice

This is due to increased haemolysis of red blood cells in the spleen which increase the amount of,
circulating bilirubin and if hypoxia developes, the efficiency of hepatocytes activity is reduced.
Forinstance when the liver cells remove bilirubin more slowly than it‟s produced.

In genetic disorder of red blood cells i.e. hereditary spherocytosis, here the red cells are smaller,
rounder, more fragile than normal ( has spherical shape not like the normal biconcave disk shape
of red blood cells) therefore they tend to get trapped into the narrow passages particularly in
the spleen and they break leading to haemolytic anaemia, neonatal haemolytic jaundice and in
severe malaria, Drugs like cephalosporins and blood incompatibility.

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Signs and symptoms

 Yellowish skin and sclera

 Increased bilirubin levels
 Dark yellow to brown urine
 Anaemia

Obstructive jaundice

This is due to the obstruction to the flow of bile in the biliary tract. This results into redirection of
excess bile and it‟s by-products into the blood. Bile contains many by-products, one of which is
bilirubin a pigment derived from dead redblood cells and this gives the characteristic yellow
appearance of jaundice in the skin, eyes and mucus membrane.

Any type of obstruction that blocks the flow of bile from the liver can cause obstructive jaundice
most commonly gallstones.

Other causes of obstruction may include;

 Inflammation
 Tumours
 Trauma
 Pancreatic cancer
 Narrowing of the bile ducts secondary to inflammation
 Structural abnormalities present at birth.

Hepatocellular jaundice/ Hepatic jaundice

This is as a result of damage to the liver it‟s self by e.g.

 Viral hepatitis
 Toxic substances such as drugs
 Amoebiasis(amoebic dysentery)
 Cirrhosis

The damaged hepatocytes may be unable to;

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  Remove unconjugated bilirubin from the blood
 Conjugate bilirubin
 Secrete conjugated bilirubin into bile caniliculi

Signs and symptom

 Usually very deep in light skinned people

 Faeces are pale
 Dirty brown urine
 Constipation.

Overview of cholecystitis

Cholecystitis is the inflammation of the gallbladder.

Acute cholecystitis usually follows obstruction of the cystic ducts by gallstones or blockage by a
tumour the obstruction increases pressure within the gallbladder leading to ischaemia of the
gallbladder walls and the mucosa.

Chemical and bacterial inflammation often follows.

The ischaemia can lead to necrosis and perforation of the gallbladder walls. In acute cholecystitis,
the gallbladder wall becomes grossly thickened and reddish with subserosal hemorrhage.

Clinical presentation of acute cholecystitis

 Abrupt onset
 Biliary colic pain: pain involves the entire right upper quadrant of the abdomen and may
radiate to the back, right scapula or shoulder. Movement or deep breathing may
aggreviate the pain. The pain usually lasts longer than biliary colic continuing for 12 to 18
hours. The pain is due to increased pressure in the gallbladder and spasm of the
gallbladder.
 Anorexia
 Nausea and vomiting
 Fever
 Rigors and chills

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  Right upper quadrant muscle guarding and rebound.
 A postive Murphy‟s, an inspiratory arrest with deep palpation in the right subcostal area.
This is a characteristic of acute cholecystitis.
 Acute cholecystitis is a medical emergency

Aims of management of acute cholecystitis

– To relieve pain
– To control spasm of the bile duct
– To maintain fluid and electrolyte balance
– To prevent further complications

This is a medical emergency; therefore doctor should be called as soon as possible meanwhile the
followings are done.

Position: Patient s put in a fowler position to reduce pressure on the inflamed gall bladder.

Oxygen is administered to counteract the inspiratory arrest as quick assessment is being carried
out.

1. Quick assessment is done involving both subjective and objective data; the subjective includes
pain on the right upper quadrant of the abdomen radiating to the back and right shoulder,
nausea and vomiting, lack of appetite.

Objective data will includes fever, rigors and chills, and tenderness of the right upper quadrant of
the abdomen on palpation, vital observation are taken; temperation, pulse, respiration, blood
pressure putting much empathy on temperature aand respiratory rate.

This is because bacterial infections are always present in acute cholecystitis and may cause an
elevated temperature and respiratory rate. Vital observations are repeated 4 hourly.

Specific observation

Observe for signs of dehydration

Tenderness of the right upper quadrant of the abdomen.

Observe for signs of shock due to pain and dehydration

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When doctor comes he may do a reassessment and may order for the following investigation.

Investigations

Serum bilirubin measurement: elevated direct (conjugated) bilirubin may indicate bile flow
obstruction in the biliary tract.

Complete blood count (CBC): This may indicate infection and inflammation if the white blood cells
are elevated.

Serum amylase and lipase measurement: this help to identify possible pancreatitis related to
common ducts obstruction.

Abdominal X-Ray: this may show gallstones that have high calcium content.

Ultrasonography of the gallbladder: this is to examine for cholelithiasis and assess emptying of
the gallbladder.

Oral cholecystogram: this is performed by using a dye administered orally to assess the
gallbladder‟s ability to concentrate, store and secrete bile.

Gallbladder scan: this is done to diagnose cytiic duct obstruction and acute or chronic cholecystitis.

Specific nursing care

1) Oxygen administration to aid breathing since Mr. Ogwang will experience inspiration arrest
due to pain
I. Psychotherapy
II. A positive nurse patient relationship is established with Mr. Ogwang,all procedures to be
done on him are explained to him and he is involved in the care, this allays his anxiety
and ensures his comfort.
III. Pain management
 Complete bed rest to reduce pain.
 Mr. Ogwang is placed in fowlers position, this will help reduce pressure on the
inflamed gallbladder.

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  He is health educated on the relationship between fat intake and pain since fats
entering the duodenum initiates the gallbladder contraction causing pain when the
gallstones are present in the ducts.
 Nil per Os: all oral food and drinks are withheld during episode of pain,this helps to
relieve nausea and vomiting.
 Analgesics are given as prescribed by the doctor eg oral morphine 5-10mg stats.
IV. Decomposition of the stomach
A nasogastric tube is inserted and connected to low suction to empty the stomach content.
This will reduce the amount of chyme entering the duodenum and stimulus for gallbladder
contraction thus relieving nausea, vomiting and pain.
V. Rehydration
 An intravenous line is established
 Mr. Ogwang is given intravenous fluids like normal saline alternated with dextrose
5% since he on nil per Os.
 A fluid balance chart is introduced recording both fluid intake and output.
VI. Bladder care
A catheter is inserted for continuous bladder drainage since the patient will be on
complete bed rest.

Medical management

Chemotherapy

Doctor may prescribe the following dugs;

 Morphine or pethdine 50mg- 100mg

 IV ceftriazone 2g bd.
 IV metronidazole 500mg 6 hourly
 IV ciprofloxacin 500mg bd
 IV chlorpromazine 25-50mg to decrease the secretion and counteract smooth muscle spasm.

Daily nursing care

 Bladder care: catheter is passed to drain urine and amount recorded in the fluid balanced
chart.

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  Oral care: patient‟s mouth is cleaned
 Bowel care
 Exercise
 Occupation therapy
 Continuous reassurance.

NB: An alternative policy of conservative management involves, discharge of the patient after the
acute attack has resolved, with readmission for elective cholecystectomy after about 6 weeks, by
which time the inflammation has usually settled however there is a risk of further acute attacks or
another manifestation of gallstone disease such as acute pancreatitis.

Even if delayed, cholecystectomy is preferred, the acute may not settle necessitating
cholecystectomy on the same admission.

After 2 days Mr. Ogwang is prepared for surgery. Cholecystectomy is done which is the surgical
removal of the gallbladder.

This is because cholecystectomy is the definitive treatment of acute cholecystitis. Early

cholecystectomy offers patients a definitive solution in one hospital admission, Quick recovery time
and an earlier return to work.

Doctor will decide on the type of Cholecystectomy. He may either do laparoscopic or open
Cholecystectomy but laparoscopic cholecystectomy is the choice

Pre-operative care

 Explain the procedure and postoperative expectation.

 Health education on pain management ,deep breathing, exercise ,mobilization , turning
bed .This teaching and explanation reduces anxiety and promotes rapid postoperative
recovery
 Position
 Analgesics
 IV line
 NG tube
 NPO

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  FBC
 Remove prosthesis,dentures,jewellery if present
 Mr. Ogwang is requested to consent for the operation.
 Theatre is informed.
 Blood for estimating ,grouping and cross matching and book blood

Morning of operation

 Skin care is done

 Premedication e.g. atropine
 Patient is dressed on theatre gown and wheeled to theatre

In theatre

Either laparascopic or open Cholecystectomy is performed depending on the decision of the

surgical team and the condition of Mr Ogwang.

Post-operative care

Post-operative bed is prepared with all its accessories in good working condition.

Two nurses go to the theatre to receive the patient with the observation tray .

They take patients vitals and if satisfactory, the patient is wheeled back to the ward.

Specific nursing management

 Position
Patient is put in a recumbent position with the head turned to one side
 Care of theIV line; IV line must be flowing in order to prevent post operative shock.
 Care of the NG Tube; This should be kept in situ and patent for continuous suction.
 Care of the T tube if in place
– Ensure that the tube properly connected to sterile container , keep the tube below the level of
the surgical wound. This position promotes the flow of bile and prevents backflow caustic bile
on the skin.
– Monitor drainage from the tube for colour and consistence, output recorded. Normally the
tube drain up 500ml in the first 24hours after surgery, drainage decreases to les than 200ml

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 n 2-3 days and is minimal thereafter. Drainage may be blood tinged initially, changing to
green brown. Report excessive drainage immediately (after 48 hours drainage greater than
500ml is considered excessive.
– Patient is put in a fowlers position this promotes gravity drainage of bile.
– Asses skin for bile leakage .Bile irritates the skin.
– Teach the client how to manage the T tube when ambulating, turning in bed and performing
daily activity .Direct pulling or traction on the tube must be avoided .

Pain management

Patient is given prescribed analgesics as soon as he wake up

Psychotherapy

Mr. Ogwang is oriented on the ward and welcomed from theatre. All procedure and treatment to
be given are explained in order to allay anxiety.

Physiotherapy,

Assisted to chair at bed side as allowed .Early deep breathing, coughing ,passive exercise
followed by active exercise promotes lung ventilation and circulation reducing the potential for
postoperative complication. Assist to cough and deep breath or use incentive spirometer every 1-
2 hours while awake .Splint abdominal incision with blanket or pillow during coughing . The high
abdominal incision of an open Cholecystectomy interferes with effective coughing and deep
breathing increasing the risk of atelectasis and respiratory infection.

Nutrition

 Advance to oral intake from ice chips to regular diet as tolerated. Oral intake be rapidly
resumed due to minimal disruption of the gastrointestinal tract during surgery.
 Low fat diet may be given if bile flow is reduced.
 Patient eats nutritious diet and avoid extensive use of fatty diet.
 Food is only to the patient after the doctor and dietician have confirmed.

Infection prevention

Prophylactic antibiotics are given as prescribed

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Daily nursing care

 Bladder care
 Bowl care
 Hygiene
 Early ambulation
 Turning 2 hourly
 Psychotherapy

If Mr. Ogwang was done laparascopic Cholecystectomy he may be discharged home after 24
hours or more depending on the doctors decision with the T tube in situ .

Advice on discharge

 If Mr Ogwang is discharged home with the T tube , he is taught how to care for it , clamp
it and signs of infections .
 He is advised to report early signs of infection to the hospital for prompt treatment.
 The patient is referred to the dietician or nutritionist for diet counseling .
 Avoid lifting heavy objects.

Complications

 Chronic cholecystitis
 Gall bladder perforaton with peritonitis
 Gall stone ileus(obstruction of the small intestine by gall stone)
 Empyema of the gallbladder
 Gangrene
 Fistula formation with the adjacent organs eg duodenum ( cholecystoduedenal fistula)
 Carcinoma of the gallbladder

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Question 38

Mr. Samuel a 30 yr old peasant has been presented to OPD with all features of tetanus.
a) Outline the clinical features of tetanus?
b) Describe his management from admission up to discharge ?

Solution

Definition

The word tetanus - a Greek word - tetanos meaning “to stretch”.

Tetanus is a surgical condition caused by clostridium tetani bacilli - affects the nervous system –
(motor neurone) - causing uncontrolled contraction of muscles (muscle spasms)

Cause- Clostridium tetani bacilli (anaerobic) - found in the gut of animals like sheep, cow, goats
and in dust

Incubation period; 2-14days

Mode of spread; Contact with an open skin

Types of form of tetanus

 Generalised tetanus
 Localised tetanus
 Neonatal tetanus
 Cephalic tetanus

Pathophysiology of Tetanus

Spores of clostridium tetani enter an open wound they germinate and produce toxins called
Tetanospasmin.

Tetanospasmin is absorbed by the peripheral nerves

taken to the spinal cord where they block the action of inhibitory enzyme at the motor neurone
synapse and

interfere with the transmission of neuromuscular impulses.

As a result even minor stimuli cause uncontrolled muscle spasms.

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Clinical features of Tetanus

 Lock jaw or trismus  Dehydration

 Stiff neck  Drooling
 Tetanus smile (risus sadonicus)  Opisthotonos
 Photo phobia  High blood pressure
 Profuse sweating
NB. A patient with tetanus is alert

Symptoms

 Fever
 Headache
 Raised eye brows
 Dysphagia
 Irritability
 Urine and faecal incontinence

Typical opisthotonos Opisthotonos

Risus sadonicos (tetanus smile)

Causes of death in patients with Tetanus

 Hypoxia  Cardiac arrest

 Aspiration  Exhaustion

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Management of tetanus

Aims

– To prevent hypoxia – To prevent complications

– To control spasms – To restore function
– To neutralise toxins
Management at the Casualty Department

Tetanus is a surgical emergency hence intervention and team work is needed quickly and smartly

Emergency care at OPD

 Call for help and ensure safety of the patient

 Inform the doctor or physician
 Admit temporarily and take quick collateral history concerning the condition and patient
 Put the patient in a semi prone position (left lateral)
 Take vital observations i.e TPR/BP, oxygen saturation and record them
 If oxygen saturation is declining administer oxygen to treat and prevent hypoxia
 The doctor may order the following investigations e.g. random blood sugar, full blood
count
 The doctor may prescribe the following drugs

 Intramuscular diazepam 20mg 6hrly

 Human tetanus immunoglobulin 1500iu given intramuscularly

As the admission procedure is being done, there after Mr. Samuel will be transferred to a male
surgical ward.

Ongoing Management on Ward

Admit Mr. Samuel in an isolated, clean, quiet, darkened room in a warm clean bed.

Position: semi prone position (recovery)

History; Detailed history is taken and recorded

 The doctor on ward is informed about the patient

 Everything possible is done to decrease noise even when opening the door
 An intravenous line is passed for intravenous access
 A naso gastric is passed to empty the stomach
 A urinary catheter is passed to empty the bladder

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Ongoing Management on Ward observations

 Continuous monitoring of vital signs is done, interpreted, and recorded

 The doctor will do a general examination to rule out cyanosis, dehydration, lung condition
 Mr. Samuel will be put on spasms chart and spams monitored

Date Body part Duration Frequency Time

 Continue monitoring and control spams

Pharmacological management

 The doctor on ward may prescribe the following drugs;

 Human tetanus immunoglobulin 1500iu IM into multiple sites - Neutralize circulating toxins

Controlling spasms

Diazepam 20mg 6hrly intravenously or chlorpromazine 25-50mg intramuscularly orMagnesium

sulphate 4g

Prevent further toxin production

 Metronidazole 500mg 6hrly intravenously for 10days

 Benzyl penicillin 1000000units (600mg) 4hrly for 10days usually with an aminoglycoside
e.g. gentamycin –

Antibiotics -Treat bacterial infections for example pneumonia

Anticoagulants; to prevent deep venous thrombosis e.g. heparin 10000iu/sc

Control blood pressure with nifedipine 20-30mg twice daily

Specific nursing care

 Maintain a clear airway – semi prone (recovery)

 Avoid noise, bright light and unnecessary touching of the body as it can stimulate spasms
 Prevent aspiration of fluids into the lungs by proper positioning

Feeding

 At first we will consider total parenteral nutrition with dextrose 50% as prescribed
 A naso gastric tube to empty the stomach hence preventing aspiration

Prevention of dehydration

 Intravenous fluids will be administered according to the doctor‟s orders

 Monitor fluid intake and output using a fluid balance chart

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  Maintain a 1.5-2l urine production per day

General hygiene

Prevent pressure sores by;

 4-6hrly turning & treatment of pressure areas

 Changing wet & soiled linen and proper bed making

Oral care;

 This is emphasised due to the excessive salivating thus preventing complications

 Care of the wound
 If present aseptic technique is used to dress it

Bladder and bowel care

 Since a catheter was passed so we ensure the urinary bag emptying

 In case of faecal impaction a stool softener might be given

Physiotherapy

 Passive exercise at first then,

 Active exercise as the condition improving
 Coughing exercise to prevent pneumonia

Health educating the patient and relatives;

 About the disease

 How it is spread or contracted

Prevention

 By avoiding to walk bare footed

 Putting on protective gears when going to dig of farm e.g boots
 In case you get a wound do not apply soil or dung but should be washed and cleaned
with soap & clean water if possible dressed aseptically.
 Getting booster doses of tetanus toxoid every after 5yrs
 Health educating others at home and encouraging them to get booster doses

Advice on Discharge

 When Mr. Samuel is well the doctor will consider a discharge and the following advice will
be provided,
 To comply with the prescribed treatment

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 Continue with the balanced diet
 Adhere to the information provided in the health education
 Continue with physicals
 Come back for review
 Take fluids to avoid dehydration

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 PHARMACOLOGY SECTION
Question 39

Cate aged 38 years was diagnosed with rheumatoid arthritis by the rheumatologist in a
private clinic. He prescribed Indomethacin 50mg 8 hourly to be taken after a meal. After two
weeks of continuous use of the medicine, Cate developed heart burn which she associated
with the intake of the medicine.

a) Define rheumatoid arthritis.

b) Outline the criteria used to diagnose rheumatoid arthritis in primary care.
c) Explain the pharmacology of the drugs used in the treatment of rheumatoid arthritis
including the nursing implications.

Solution

a) Rheumatoid arthritis is an autoimmune disease characterized by severe inflammation and pain

in the affected joint.

b) Criteria used in the diagnosis of rheumatoid arthritis

A patient is said to have rheumatoid arthritis if 4 or more of these are present for at least 6
weeks.

 Morning stiffness lasting more than 1  Presence of rheumatoid nodules

hour. especially around the elbows
 Involvement of 3 or more joint areas  Elevated rheumatoid factors
 Arthritis of hand joints  Radiographic changes
 Symmetric joint involvement
c) Pharmacology of the drugs used in rheumatoid arthritis

Drugs used in the treatment of rheumatoid arthritis are classified into 3;

 Non-steroidal inflammatory drugs

 Glucocorticoids (steroids)
 Disease modifying drugs

Non-steroidal antiflammatory drugs (NSAIDs)

NSAIDs are drugs of first choice in the treatment of rheumatoid arthritis.

They reduce inflammation and pain associated with rheumatoid arthritis by inhibiting the
prostaglandin synthesis.

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NSAIDs commonly used in the treatment of rheumatoid arthritis include; indomethacin, aspirin,
diclofenac, piroxicam, ibuprofen, aceclofenac, meloxicam and celecoxib.

NSAIDs mainly suppress inflammation and pain in order to improve quality of life of the patient
but do not prevent the progression of the disease.

Side effects associated with the use of NSAIDs include heartburn, nausea and vomiting, peptic
ulcer disease and GIT bleeding.

Heartburn can be reduced by administering NSAIDs after a meal.

Development of peptic ulcers disease which usually occurs on long term use of non selective
NSAIDs can be prevented by co-current use with omeprazole or using a selective NSAID.

Glucocorticoids

Glucocorticoids act by suppressing inflammation thus relieving pain and joint stiffness.

Steriods in common use include prednisolone, dexamethasone, betamethasone, triamcinolone and

methylprednisolone.

These drugs can be given orally or in form of depot injection.

They are usually recommended for patients who do not respond to NSAIDs and are usually given
for a short period of time to minimize the long term side effects.

Just like NSAIDs, steroids also offer symptomatic relief but do not delay the progression of the
disease.

Long term side effects of steroids include diabetes, hypertension, osteoporosis, glaucoma,
immunosuppression and gastric ulcers.

Disease modifying antirheumatic drugs (DMARDs)

DMARDs commonly used in Uganda include chloroquine, hydroxychloroquine, methotrexate and

sulfasalazine.

Unlike NSAIDs and steroids, DMARDs reduce inflammation and also prevent joint damage thus
delaying the progression of the disease.

These drugs have a slow onset of action and full benefits to the patient can be realized after one
month.

It is recommended that DMARDs be started early enough i.e. within the first 3 months of diagnosis
before severe joint damage occurs.

DMARDs are associated with severe side effects therefore regular monitoring of the liver and
kidney function is recommended.

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Patients using chloroquine and hydroxychloroquine need regular eye checkups since they are
associated with retinol damage (visual loss).

Question 40

Write short notes on the following drugs

a) Ergometrine
b) Oxytocin
c) Misoprostol

Solution

a) Ergometrine

Ergometrine is a uterine stimulant which is available in injection form for IM and tablets for oral
use.

It acts by stimulating the uterine contractions leading to a decrease in uterine bleeding.

Ergometrine is mainly used in the treatment of postpartum haemorrhage.

It should never be administered before complete delivery of the placenta.

Side effects associated with the use of ergometrine include nausea and vomiting, headache,
dizziness, palpations, hypertension, chest pain, abdominal pain and blurred vision.

Ergometrine should not be used in the following cases;

 Patients with severe hypertension

 Induction of labor
 Severe angina pectoris
 Patients with history of allergy to ergometrine

b) Oxytocin

Oxytocin is a uterine stimulant which is available in injectable form for IM and IV infusion.

It is recommended in the treatment of the following conditions.

 Postpartum haemorrhage
 Post abortion haemorrhage
 Induction of labor
 Prevention of postpartum haemorrhage

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Common side effects associated with the use of oxytocin include;

 Nausea and vomiting  Hypotension

 Headache  Tarchycardia
 Uterine rupture

Oxytocin should not be used in the following cases;

 Fetal malpresentation
 Labor induction when vaginal delivery is contraindicated
 Severe pre-eclampsia
 Fetal distress
 Previous uterine surgery
 Hypertonic uterine contractions

When using oxytocin, monitor the fetal heart rate and uterine motility.

c) Misoprostol

Misoprostol is available in tablet form of 200mcg.

It is used in the treatment of postpartum haemorrhage, incomplete abortion.

Side effects associated with use of misoprostol include diarrhoea, abdominal pain, nausea and
vomiting, dyspepsia, flatulence (gas in the stomach), abnormal vaginal bleeding.

Misoprostol should not be used in patients with a history of allergy to it.

Question 41
a) Briefly explain the pharmacology of typical antipsychotics.
b) Outline how the side effects associated with typical antipsychotics can be managed.
Solution

Definition:Antipsychotics are drugs used in the treatment of psychotic disorders such as

schizophrenia or mania.

They are classified into two major groups i.e. typical and atypical antipsychotics.

b) Pharmacology of typical antipsychotics

Typical antipsychotics

Typical antipsychotics are also called first generation antipsychotics. They were the first drugs to
be used in the treatment of schizophrenia and more effective against positive symptoms.

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Typical antipsychotics act by blocking dopamine 2 receptors thus relieving the symptoms of
schizophrenia.

They also block other receptors in the body which are responsible for a wide range of indications
and side effects.

They are further divided into two major groups according to chemical structure.

Class Examples
Phenothiazines Chlorpromazine , thioridazine, fluphenazine, trifluoperazine
Butyrophenone Haloperidol

Indications

Typical antipsychotics are used in the treatment of;

 Schizophrenia  Intractable hiccups

 Acute mania  Tetanus as an adjunct treatment to
 Severe anxiety control convulsions
 Nausea and vomiting
The side effects associated with the use of use typical antipsychotics include;

 Weight gain  Increased appetite

 Muscle stiffness  Constipation
 Decreased sexual function  Sedation
 Dry mouth  Drug induced Parkinsonism
 Blurred vision
Note:

 The side effects of the typical antipsychotics can be reduced by using the lowest effective
dose and use of depot injection that releases a small amount of drug into the body.
 Dryness of the mouth can be minimized by increased intake of water or chewing gum.
 Weight gain and increased appetite can be prevented through a proper diet.

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 GYNECOLOGY, OBSTETRICS/NORMAL MIDWIFERY
Question 42

a) Draw a diagram of a uterus indicating sites of fibroids.

b) Differentiate between benign and malignant tumors.
c) Give the management of the mother after myomectomy within the first 48 hours.
d) What is the specific advice you would give this mother on discharge.

Solutions

Introduction

Definition

Fibroids are noncancerous growths of the uterus that often appear during childbearing years.

Fibroids are muscular tumours that grow in the wall of the uterus.

Signs and symptoms

The majority are asymptomatic i.e about 75% and are detected during routine examination.

 Metrorrhagia and dysmenorrhoea especially in polyps.

 Frequency of micturation or retention of urine from pressure on bladder
 Oedema or vericose veins of leg.
 Hemorrhoids from pressure on the pelvic veins.
 Tumour may be felt on palpation of the abdomen.
 On V.E the uterus is felt enlarged and irregular.
 Pain during intercourse

Causes of fibroids

 Hormones e.g estrogen and progesterone causes lining to regerate during each menstrual
cycle and may stimulate the growth of fibroids.
 Family history may develop it as well.
 Pregnancy increases the production of estrogen and progesterone in your body which
may develop and grow rapidly while you are pregnant.

People at risk

Fibroids are commonly being detected in about 20% of women over 30years;

 Obesity
 A family history of fibroid

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  Null parity
 Over age i.e 35years when has never conceived
 Race i.e being of African American descent
 High body weight

a] A diagram of uterine fibroids.

Types of fibroids

1. Interstitial or intramural fibroids 75%: They grow within the myometrium. They may grow
larger and actually stretch the uterus.

2. Sub-serosal or sub-peritoneal fibroids 15%: These are intramural fibroids that are
pushed outwards the peritoneal cavity, they are partially or completely covered by
peritoneum.

3. Pedunculated fibroids: When the sub-mucosal tumors develop a stem[a slender base that
supports the tumors],they become pendunculated fibroids and may come out through the
cervix.

4. Submucosal fibroids: They protrude into the uterine cavity and lie under the
endometrium.

5. Cervical fibroids: These are located in the wall of the cervix.

b] Difference between Benign and malignant tumours

Benign Tumours

 Simple tumours

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  Do not endanger life
 They are encapsulated and resemb le the tissues of origin
 They grow slowly and localized
 Do not invade or form secondary deposit in other organs

Malignant tumours

 Cancerous tumours
 Endanger life
 Are not encapsulated and do not resemble tissue of origin
 Grow very fast and may spread through lymph and blood stream
 Invade and destroy the neighboring organs [Metastasis]

c] Management of myomectomy in the first 48 hours

Aims of management

 To promote recovery of the mother

 To prevent infections
 To prevent other complications
 To relieve pain and provide psychological care.

On the ward;

 Post-operative bed is made with it‟s all bed accessories like oxygen cylinder, vital signs
tray, drip stand, bed blocks, suction apparatus, emergency tray.
 Call from theatre to the ward shall be received; 2 nurses will go to collect the mother with
a stretcher.

In the theatre;

The two nurses will get the report from the,

Anesthetist on;

 Anesthesia used.
 Amount of intravenous fluids used in theatre.
 Vital observation of the mother during operation
 Any treatment given during operation
 Any blood transfusion –how many units used.
 General condition of the mother during operation.

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2. Doctor on;

 What operation was done and what was found.

 Treatment to be continued in the ward.

3. Report from recovery room nurse;

 Vital signs of the mother.

 Level of consciousness
 Bleeding from the operated site.

The two nurses will repeat the vital signs if they are satisfactory, the mother will be taken to the
ward.

On the ward;

 At least 3nurses will be needed to lift the mother gently to the bed.
 Mother will be put gently on the warm bed.

Immediate care in the ward,

 Position: Mother will be put on supine position, head turned to one side to prevent the
blockage of airway.
 Vital observation: TPR/BP taken1/4-2HRS,1/2-2HRS,1-2HRS then changed according to
the patients chart. These are important as they serve as baseline for further management.
 Physically: Observe the operated site for bleeding .If the dressings are soiled ,add more
gauze ,if it is increased add more dressing and inform doctor.
 Observe the infusion site if it is well patent, if fluids are flowing at the right rate.
 Observe for urinary bag the output if full empty the bag and record in the fluid balance
chart.

On recovery from anesthesia;

 Give prescribed analgesics like pethidine 10mg 8hrly x 3doses,then change to mild
analgesics like diclofenac 75mg 8hrly,then paracetamol 1g x3days.
 Change the gown, give her mouth wash.

Subsequent nursing care;

Care of the wound: The wound is not disturbed. Dressings are only changed when soiled or
depending on surgeon, observe the dressing for bleeding, and never touch the wound with dirty
hands.

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Hygiene:

 Bed bath is given in the first 12hours until the mother is able to move to the bathing
shelter.
 Bed linens are changed daily-bed is protected too.
 Clean gown is given daily.
 Oral nursing care is done daily and rinsing in between meals.

Diet:

 Mother will nil per oral till bowel sound is present .At this time mother will be on
prescribed iv fluids like normal saline ,dextrose 5% input and out should be kept up date
and recorded in the fluid balance chart.
 When bowel sound is present, mother will be started on oral sips then light diet like
porridge.
 The diet should be well nourished and more especially vitamins & proteins to promote
healing of the wound.

Exercise:

 Passive exercise are done in bed like leg exercise to promote blood circulation to the
lower limbs.
 Deep breathing exercise to prevent hypostatic pneumonia.
 As the patient‟s condition improves then sitting up, moving from bed to chair, and walks
around the bed/ward.

Care of the bladder:

 When catheter is still insitu its cared for then removed after 24 hours when the patient‟s
condition is stable.
 Mother will be encouraged to empty the bladder to avoid urine retention.
 Bed pan is offered to the mother within 12hours then she will be encouraged to empty the
bowel frequently to prevent constipation.

Rest and sleep.

Psychological care:

 Continuous reassurance to the mother is done.

 Nurse patient relationship is established to allay anxiety.
 Relatives are allowed to give morale, support to the patient.
 If she is a learnt mother she will be given newspapers, books to read to occupy her mind.

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d] Specific advice to the mother on discharge

 To come for review after 2weeks.

 To join family planning to delay pregnancy and conceiving should be after 6months.
 To attend antenatal care as soon as she realizes that she is pregnant.
 To continue taking the prescribed drugs or medications.
 To deliver in the hospital

Complications of fibroids

 Abortion and pre mature labour

 Inflammation of tissues and tissue necrosis
 Increase in the size of pregnancy above the expected weeks.
 Severe pain and pyrexia
 Interference with muscle action resulting in uterine inertia
 PPH due to poor uterine contractions
 Sub involution and increase in lochia
 Infertility

Question 43
[a] Define the term vaginal fistula.
[b]Outline the causes of vaginal fistula.
[c]Using the nursing process give the management of a woman after repair of vesico vaginal
fistula.
Solutions
[a]. A fistula is an abnormal passage or communication between two hollow adjacent organs of
the body.
A vaginal fistula is an abnormal passage or communication between the vagina and adjacent
organs of the body.
Vaginal fistula is classified into the following based on the site
Vesico vaginal fistula; an abnormal passage or communication between the urinary bladder and
vagina, urine escapes into the vagina causing true incontinence.
Recto vaginal fistula; an abnormal connection or communication between the rectum and vagina
with involuntary escape of feaces or flatus into the vagina.
Urethral vaginal fistula; an abnormal passage or connection between the vagina and the
urethra.

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Uretero vaginal fistula; an abnormal communication between the volt of the vagina and the
ureter.
(b)Causes of vaginal fistula
The causes of vaginal fistula are categorized into two i.e.
Indirect and direct causes
Indirect causes / Risk factors
 Lack of education  Traditional practices
 Lack of access to ANC
 Poverty
 Malnutrition
 Sexual violence
Direct causes
Categorized basing on the type of fistula
Causes of vesicovaginal fistula
Obstetrical causes

Ischemic
The fistula results from prolonged compression effect on the bladder base between the fetal head
and symphysis pubis (cephalo pelvic disproportion) in obstructed labour. The compression causes
ischemic necrosis, sloughing and fistula in 3 to 5 days following delivery.

Traumatic
Instrumental vaginal delivery such as destructive operations, forceps delivery especially with
kiellands forceps
Abdominal operations such hysterectomy, fistula follows usually soon after delivery

a) Gynecological causes
Operative injury; during operations like anterior colporrhaphy, abdominal hysterectomy or
removal of Garter‟s cyst.

Traumatic; injury to anterior vaginal wall and bladder wall following fall on a pointed object,
use of appointed object, use of a stick for criminal abortion.

Malignancy; advanced carcinoma of cervix, vagina and bladder may produce fistula by direct
spread.

Radiation; Ischemic necrosis may occur when carcinoma of cervix is treated by radiation in 1-2
years.

Infective; chronic granulomatous, lesions such as vaginal tuberculosis, lymphogranuloma venerium

and actinomycosis may cause fistula.
I. Causes of urethro vaginal fistula
Injury inflicted during anterior colporrhapy, urethroplasty or sling operation for stress
incontinence

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Residual fistula left behind following repair of vesico urethro vaginal fistula
II. Causes of uretero vaginal fistula
Congenital;The aberrant ureter may open into the vault of the vaginal, uterus or into urethra.

Acquired; this is the commonest type and usually follows trauma during pelvic surgery e.g.
cervical fibroids, abdominal hysterectomy, radical hysterectomy, endometriosis.

III. Causes of rectal vagina fistula

Obstetrical
 Incomplete healing or unrepaired recent complete perineal tear
 Obstructed labour
 Instrumental injury during destructive operation

Gynecological
 Following incomplete healing of old perineal tear
 Fall on sharp pointed objects
 Malignancy of the vagina, cervix or bowel
 Radiations
 Lymphogranuloma venerium
 Diverticulitis of sigmoid colon when the abscess bursts into the vagina
 Crohn‟s disease involving the anal canal or lower rectum

Congenital
The anal canal may open into the vestibule or into the vagina.

c) Management using the nursing process

Assessment

 Pain
 Immobility
 Hemorrhage
 Hypotension

Nursing Expected Goal Planning Intervention Rationale Evaluation

diagnosis out come
Pain The patient The patient -To reassure the -Patient re- -To ensure After 6 hours
related to should should report patient. assured. psychological the patient
surgical report control of -To put the -Patient put understanding reports no
repair control of pain within 6 patient in a in a of the repair. pain
evidenced pain. hours. comfortable comfortable
by patient position. position. -To ensure
verbalizing -To give patient‟s
pain. prescribed -Prescribed comfort
analgesics. analgesics
given -To relieve
pain.

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Risk for Regain skin The patient Aseptic -Aseptic -To reduce Patient did
infection integrity should remain technique while wound chances of not develop
related to without infection free caring for dressing. contamination. any infection
disruption experiencing throughout indwelling -Frequent -To prevent throughout
of normal symptoms of hospitalization catheter. changing of other hospitalization
skin infections. Checking vital pads. ascending
integrity Patient observations -Monitor infections.
by surgical should regularly ¼ , ½ vitals. -To monitor
incision. remain 2hourly and Take a lot any sign of
afebrile 4hourly of oral infection
fluids
Risk for The wound Abstinence for To counsel the Counseling To give a After 6
wound should 6 months. couple to done deep months,
dehiscence remain intact understand the understanding patient
related to until healing. necessity of of the reported no
early abstinence to condition or sexual
resumption allow healing fistula to the intercourse
of sexual and prevent couple. and the
intercourse. broken repair. wound had
complete
healing.

Question 44

Mother comes to the maternity centre having been infected with HIV/AIDS

i. What method are you going to use to allay her anxiety?

ii. What are the qualities of a good counselor?
iii. What are the steps of counseling?
iv. What are the principles of counseling?

Definition of counseling

 Is the helping of an individual in a state of difficult, confusion and dilemma to realize his
current state, make decisions and find solutions to his/her problems. Counseling helps a
client to cope effectively with the situation. Through personal relationship with the client,
the counselor will help the client to come up with realistic and achievable goals.
 Is a confidential communication between a client and a care provider aimed at enabling
the client to cope with stress and take personal decisions relating to HIV/AIDS.

The counseling process include

 Evaluation of risk of HIV transmission

 Facilitation of preventive behavior and evaluating coping mechanisms when the client is
confronted with positive results (WHO).

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What method are you going to use to allay her anxiety?

G- Greet

A- Ask

T- Tell

H- Help

E- Explain

R- Return

GREET

1. Welcome the client on arrival

2. Meet in comfortable private place (provide privacy)
3. Assure the client of confidentiality
4. Express caring, interest and acceptance by words and gestures throughout the meeting

ASK

1. Ask client reason for thevisit

2. Encourage client to do most of talking
3. Ask open ended questions
4. Pay attention to what the client said and how it was said and follow up with more
questions
5. Put yourself in the client‟s shoe-understand without criticism preferable or judgment
6. Ask client‟s preferences

TELL

1. Start discussion with client‟s preferences

2. Give important information to client‟s decision
3. Avoid information overload
4. Use words familiar to the client
5. Use samples, drawings or other counseling aids

HELP

1. Let the client know that the decision is hers/his

2. Help a client to identify the full range of possible choices
3. Let the client decide
4. Ask the client to state her decision
5. Reflect the client‟s decision to confirm it
6. Make sure the client‟s choice is based on accurate understanding.

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EXPLAIN

1. Provide what the client wants

2. Explain how to get ARV‟S, place of delivery and prevention of mother to child transmission
of HIV.
3. Check the client‟s understanding
4. Ask for any question
5. Discuss STD prevention and give condoms if needed

RETURN

1. Plan the next visit if needed

2. Invite the client to come back anytime for any reason
3. Refer client for any care you cannot give
4. Thank the client for coming and invite the client to send or bring others.

What are the qualities of a good counselor?

1. Good listener. A good counselor should be a good listener. A good listener will
understand, recall all the verbal and non verbal messages the client is communicating as
he/she is telling her/his story.
2. Genuineness. The counselor should recall not to hide behind a profession façade. He/she
should be consistent in whatever he/she says. Should be sincere to himself and to the
client.
3. Warmth/unconditional posture regard
4. The counselor should appreciate and accept the client as he/she is not what he wants him
or her to be. Good attitude convinces the clients that they can be liked despite their
unlikable nature.
5. Empathy
6. A good counselor should be able to understand and experience what the client is going
through. He/she should be able to put himself into the client‟s shoes, perceive things as
he/she does and transmit this understanding back to the client. Empathy builds trust and
brings relief to the client.
7. Self-disclosure. When a counselor reveals his/her personal experience, it will make the
client to have hope (the story should be relevant). A counselor should avoid personification,
don‟t tell the client about somebody else.
8. Wisdom. A counselor should be wise on how she/he is dealing with the clients. He/she
from difficult thoughts and feelings put forward by the client make a wise statement that
that the client may use to decide where to go next in the session. During the session should
not ask questions during that will remove the client from the right track, be wise as you ask
questions.
9. Respect .A counselor should respect client‟s views and ideas. He/she should not pause a
question or come out with a statement that will shut down the client.

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 10. Confidentiality. Keeping whatever is being talked about in the session as private as
possible. Keeping the information by clients confidential builds an environment of safety
and trust for the client.
11. A good counselor should be emotionally stable
12. He/she should be sympathetic with the client
13. Congruence. This provides client with vision of a counselor is genuine understanding and
supportive nature.
14. Positive regard. A counselor must be able to build counseling relationships in a
foundation of warmth, understanding and genuine support.
15. Respect. The counselor must show respect for another person and their welfare at all
time, they must also remain impartial and non-judgmental.
16. Personal skills. Active listening, good interpersonal skills and an ability to question,
reflect and challenge attitudes and beliefs are all personal skills that can help a counselor
build a successful career.
17. Personal knowledge. A counselor should be knowledgeable in order to provide a good
counseling relationship. A counselor must also be self aware and must be in control of their
feelings, thoughts and emotions while working with the client.

What are the steps of counseling?

1. Identify the problem. Make sure that you really know the problem. Analyze the forces
influencing the behavior.
2. Plan, co-ordinate and organize the session. Determine the best time to conduct the session.
3. Conduct the session using sincerity, compassion and kindness. This does not mean you
cannot be firm or in control.
4. During the session, determine what the client/mother believes causes the problems that
bring the anxiety.
5. Using all the facts, make a decision and or plan of action to correct the problem. If more
counseling is needed, set a firm date and time for the next session.
6. Try to maintain a sense of timing as to when to use the directive or non-directive
counseling.
7. Direct counseling the counselor identifies the problem and tells the person being counseled
what to do about it.
8. Non-directive counseling the person being counseled identifies the problem and
determines the solution with the help of the counselor.

What are the principles of counseling?

 Act with care and respect for individual and cultural differences and diversity of human
experience.
 Avoid doing harm in all their professional work.
 Respect the confidences with which they entrusted.
 Promote the safety and wellbeing of individuals, families and communities.

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  Seek increase the range of choices and opportunities for clients
 Be honest and trust worthy in all their professional relationships
 A counselor should practice within the scope of their competence
 Treat colleagues and other professionals with respect, fairness and honesty. A counselor
shall not solicit clients away from other counselors.

Question 45

(a) What are the characteristics of normal labour?

(b) Outline the signs and symptoms of obstructed labour.
(c) Describe the management of obstructed labour in a health centre.
(d) Give specific complications of obstructed labour.
Solution

a) Definition of terms

– Labour
– Normal labour
– Obstructed labour
 Labour is defined as the process by which the foetus placenta and membranes are
expelled through the birth canal after 28 weeks of gestation with the aid of uterine
contractions.
 According WHO(1997),normal labour refers to as low risk throughout ,spontaneous in
onset at term(37-40 weeks) with the foetus presenting by vertex, culminating in the mother
and infant in good condition following birth.
 Obstructed labour: Refers to the failure of the foetus to descend through the birth canal
despite strong uterine contractions.
Characteristics of Normal labour

 Labour is said to be normal when it has the following characteristics.

 Starts spontaneously at term between 37 – 40 weeks of gestation.
 The foetus presents with the vertex.
 It is completed spontaneously within 18 hours.
 The baby is delivered alive and healthy.
 Blood loss does not exceed 500mls

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  No complications arise to both the mother and the baby.
b) Signs and symptoms of obstructed labour.

Early signs and symptoms

 The widest diameter of the foetal skull remains stationary about the pelvic brim because it
is unable to descend.
 Contractions are strong but there is no evidence of descent of the presenting part.
 Prolonged labour more than 12 hours.
 If due to malpresentation or malposition, this will be felt on abdominal examination.
 There is slow dilation of the cervix less than 1cm per hour.
 Membranes tend to rupture early due to poor application of the presenting part.
Late signs and symptoms

 Mother appears anxious and weak.

 In late stage, labour pains may stop when the uterus is ruptured or in a first delivery
labour pains will just stop spontaneously.
 Abnormal vital signs that is: fast pulse more than 100 beats per minute, low blood
pressure, respiratory rate about 30 breaths per minute, plus elevated body temperatures.
 Concentrated urine which may contain meconium and blood.
 Acetone in urine on urinalysis.
On abdominal examination

 Bandl’s ring: This is a retraction ring seen as an oblique ridge above the symphisis pubis
between the upper and lower uterine segments about at the level of the umbilicus. It
should not be seen or felt on abdominal examination in normal labour.
 The abdomen is irregular because liquor is drained.
 Excessive foetal movements due to foetal distress.
 Foetal heart is irregular.
On vaginal examination

 Vagina feels hot and dry due to dehydration on examination with a gloved finger.
 Oedema of the cervix.

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  Poor cervical effacement, the cervix feels like an empty sleeve.
 Oedema of the vulva including the vagina due to prolonged pushing.
 Formation of caput succedaneum, a swelling on the foetal skull.
 Evidence from the partograph that the cervical rate of dilation is less than 1cm per hour
plus delayed or failure of the foetal head descent.
The management of obstructed labour in a health centre.

This is an obstetric emergence and therefore requires immediate intervention.

AIMS

– To save the life of the mother and the baby

– To prevent complications to both the mother and baby.
– To arrange for an urgent referral.
 The mother is admitted temporarily.
 To take full history including history of labour.
 Quick observations of temperature, pulse rate, respiration and blood pressure.
 Carry out a quick general examination and listen to foetal heart, meanwhile re-assure the
patient and relatives.
 Ensure the bladder is empty such that if the obstruction is due to a full bladder, drain it by
insertion of a urinary catheter.
 Monitor vital observations, establish an intravenous line with a large bore cannula
preferably gauge 16-18.
 Administer plasma expanders such as normal saline or ringers lactate for resuscitation. If
the woman has the signs of shock, infuse with 1 litre of fluids running as quickly as possible.
 Administer 1 litre every 20 minutes till her pulse increases to atleast 60 beats per minute
and diastolic blood pressure 60mmHg or higher (below 90 mmHg).
 Start a course of antibiotics either Amoxicillin 500mg hourly or Erythromycin 600mg 6
hourly
Plus

 Metronidazole 400mg 8 hourly to counteract bacterial infections.

 Analgesics such as morphine may be given to relieve pain.

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  If the centre has laboratory services, test urine for Acetone, remove blood for grouping
and cross matching.
 Organise the transportation of the mother to a facility where emergence delivery by
caesarean section will be done to get the baby out of the uterus alive and also to save
the life of the mother.
 With a well written referral note, escort the mother, while observing the vital signs of both
the mother and foetus up to the hospital for further management.
 On the way to the hospital, continue taking foetal heart and vital observations.
 Handover the mother on arrival to the mid wife or doctor or any other staff available with
both oral and a well written referral note.
Specific complications of obstructed labour

These may occur either to the mother or to the baby.

To the mother

 Postpartum haemorrhage because of the exhaustion of the uterine muscles.

 Fistula formation with its further complications including incontinence, infections and stigma
also depression.
 Slow uterine involution.
 Shock due to severe pain.
 Rupture of the uterus due to tonic uterine contractions.
 Puerperal Sepsis due to early rupture of membranes.
 Death
To the baby

 Neonatal sepsis.
 Convulsions (fits)
 Neonatal asphyxia due to lack of oxygen to the baby.
 Death

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Question 46

a) Define acute inversion of the uterus

b) What are the causes of the above condition?
c) What is the immediate management of this condition in hospital?
d) Mention complications of acute inversion of the uterus
Solution

a) Define acute inversion of the uterus?

Is when the uterus is turned inside out completely or partially within 24 hours of delivery.

Partial inversion - the top of the uterus (fundus) has collapsed, but the uterus hasn‟t come through
the cervix.

Complete inversion - the uterus is inside-out and coming out through the cervix.

b) What are the causes of the above condition?

Although generally associated with excessive cord traction in the third stage of labour, the causes
of uterine inversion remain unexplained. But there are risk factors associated with this situation
which include:

 Tension on the umbilical cord

 Fetal macrosomia
 Excessive fundal pressure
 Ligaments laxity
 Congenital abnormalities of the uterus e.g. Unicornuate uterus
 Short umbilical cord
 Fundal implantation of the placenta
 Retained placenta and abnormal adherence of the placenta ( placenta accreta)
 Chronic endometritis
 Vaginal births after previous Caesarean section
 Rapid or long labours
 Previous uterine inversion
 Certain drugs such as magnesium sulphate (drugs promoting tocolysis)

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c) What is the immediate management of this condition in hospital?

Management

This is an obstetrical emergency where quick action has to be taken.

Aims

– Treat shock.
– To control bleeding.
– Replace the uterus.
– Prevent further complications

The important principles are:

 Concurrent maternal resuscitation with manual uterine replacement is the first line of
management.
 If the placenta is still adherent following uterine inversion – LEAVE IN PLACE to reduce
blood loss.
 Uterine rupture should be excluded prior to performing hydrostatic reduction of the uterus.

NB: Once the inversion is recognised, all oxytocic agents should be withheld until correction has
been established.

Steps include:

 Calling help from other nurses and the doctor. This should include the most experienced
anaesthetic help available.
 Reassurance of mother and attendants.
 Mother is put on lithotomy position to avoid further collapse.
 Securing further intravenous access with large-bore cannulae and commencing fluids.
 Resuscitation is usually started with crystalloid, such as normal saline or Hartmann's
solution, although some people prefer colloids from the outset.
 Inserting a urinary catheter.
 Monitor vital signs closely and record
 Take off blood for Hb estimation, blood grouping and cross matching and book atleast 2-
3 units of blood.
 Dr. may order for morphine 15mg intramuscularly to relieve pain.
 General anaesthesia is given and uterus is replaced manually.

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MANUAL CORRECTION OF THE INVERSION

JOHNSON’S MANEUVER

 Prompt repositioning of the uterus best done manually and quickly through the vagina
known as the Johnson‟s maneuver.
 Using the palm of the hand push the fundus of the uterus along the direction of the vagina
towards the posterior fornix.
 Then lift the uterus towards the umbilicus and return to its normal position,with a steady
pressure.
 This manipulation causes uterine ligaments to stretch.
When the inverted mass is pushed upwards, the uterus typically reverts promptly and
fundus returns.
 Maintain the hand in situ until a firm contraction is palpated.
 Oxytocin therapy should be administered to initiate and maintain contraction of the uterus
after replacement.

HYDROSTATIC MANEUVER (O’SULLIVAN’S TECHNIQUE)

Hydrostatic reduction is a method of reinverting the uterus by infusing warm saline into the
vagina.

Note: uterine rupture should be excluded prior to performing this procedure.

The woman may be placed in the reverse Tredelenburg positionto assist gravity and reduce
traction on the infundibulo-pelvic ligaments,round ligaments and the ovaries.

Method one

 Attach a 2 x 1 litre bags of warmed saline toa Y-Cystoscopy giving set.Additional fluids
may be required.
 Or use of a douch nozzle.
 Insert the hand into the vagina with the openend of the tubing near the posterior fornix.
 Obtain a seal at the vaginal entrance by enclosing the labia around the wrist/hand to
prevent fluid leakage.
 Infuse warmed fluid under gravity.Several litres of fluid may be required.

Method two

 Attach a 2 x 1 litre bags of warmed saline to a Y-Cystoscopy giving set.

 Gently push the inverted uterus into the vagina.
 Insert a 6cm (or appropriate sized) silasticventouse cup into the lower vagina. Avoid
pushing the cup deep into the vagina.Attach tubing toa container with warmed saline
tubing or the giving set, and then place it 1 metre above the patient.
 The pressure of the fluid builds up as several litres are run into the vagina and restores the
uterus to its normal position.

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  If leaking occurs at the introitus gently withdraw the cup until it fitsagainst the inner aspect
of the introitus.

Following the procedure the uterus should be digitally explored.The hand should be kept in the
uterus until the oxytocic therapy produces a contracted uterus.

If this fails then a general anaesthetic is usually required. The uterus may then be returned by
placing a fist on the fundus and gradually pushing it back manually into the pelvis through the
dilated cervix.

Maintain bimanual uterine compression and massage until the uterus is well contracted and
bleeding has stopped.

SURGICALMANAGEMENT

 When all attempts at manual reduction of the inversion are unsuccessful, surgical correction
might be necessary.
 Although several procedures have been described, the two most commonly cited are the
Huntington and Haultaim procedures.
 The Huntington procedure requires a laparotomy to locate the cup of the uterus formed by
the inversion. Clamps are placed in the cup of the inversion below the cervical ring, and
gentle upward traction is applied. Repeated clamping and traction continues until the
inversion is corrected.
 In the Haultaim procedure, an incision is made in the posterior portion of the inversion ring,
again through the abdomen, to increase the size of the ring and allow repositioning of the
uterus.

PRE-OPERATIVE PREPARATION

 Preparing theatres for laparotomy.

 Stabilise the woman to obtain effective anaesthesia.
 Obtain consent from the mother

Administering tocolytics to allow uterine relaxation. For example:

 Nitroglycerin (0.25-0.5 mg) intravenously over 2 minutes.

 Or terbutaline 0.1-0.25 mg slowly intravenously.
 Or magnesium sulphate 4-6 g intravenously over 20 minutes.

NB: Remember the Nitroglycerine can cause hypotension this can be reversed with Ephedrine.

Replace the uterus

 General anaesthetic or uterine relaxant is then stopped and replaced with oxytocin,
ergometrine or prostaglandins.
 Commence oxytocin therapy following uterine replacement.

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  Administer prophylactic antibiotics:
 Cefazolin 2gm intravenous – one dose only

AND

 Metronidazole 500 milligrams intravenous – one dose only

 Monitor closely after repositioning, in order to avoid re-inversion.
 Close observation of vital signs after every 15 mins
 Fundal assessment every 15 mins for 1 hour, then every 30mins until stable
 Reassess CBC
 Transfuse as necessary based on hematologic status

PATIENT/FAMILY TEACHING

 Discuss what happened, include predisposing risk factors, possible causes

 Assess patient/family‟s understanding of situation, allowing time for questions
 Encourage patient/family to express fears and concerns
 Discuss any long term implications of the inversion and haemorrhage

Summary

 In summary, uterine inversion can be a life-threatening obstetric complication. Although

uncommon, if unrecognized, severe hemorrhage and shock will lead to maternal death.
 Manual manipulation aided by tocolytic or halogenated anesthetic agents is often
successful in correcting the inversion. In the most resistant of inversions, surgical correction
through the abdomen might be needed.
 In any case, the best prognosis is achieved by prompt recognition of the condition and
immediate attempts to correct the inversion. Thus, it is important that physicians providing
obstetric care be aware of the common signs of inversion so that the diagnosis can be
determined and treatment initiated immediately.

d) Mention complications of acute inversion of the uterus

 Endomyometritis
 Damage to intestines or uterine appendages
 Severe haemorrhage (anaemia)

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  Shock due to pain (Neurogenic)
 Infection (uterine sloughing if not treated becomes chronic)
 Pulmonary embolism
 Cardiovascular system collapse
 Oedema
 Secondary infertility
 Uterine necrosis

Question 47

a) Define obstetrical emergency

b) List 10 obstetrical emergencies
c) Give signs and symptoms of impending eclampsia
d) Describe the management of a mother admitted in hospital with eclampsia in the 1st
48 hours
Definition
An obstetrical emergency is a life threatening condition that occurs in pregnancy labor and
puerperium.
LIST OF OBSTETRICAL EMERGENCIES
During pregnancy

 Ectopic pregnancy (Ruptured ectopic)

 Pre- eclampsia
 Eclampsia
During labor 1st stage of labour

 Fetal distress
 Obstructed labour
 Ruptured uterus
 Ante partum hemorrhage
 Eclampsia
 Cord prolapse
 Arm prolapse
 Maternal distress
Second stage

 Second stage its self is an emergency

 Retained second twin

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  Intra partum hemorrhage
 Obstructed labor in breech, shoulder dystosia, hydrocephalus.
 Ruptured uterus in case of hypertonic contractions
 Cord prolapse
 IUFD
 Asphyxia
Third stage

 Retained placenta
 Post partum hemorrhage 3TS( tears, tone and tissue)
 Shehan‟s syndrome (necrosis of the pituitary gland due to over bleeding
 Shock
Signs and symptoms of impending eclampsia (severe pre – eclampsia)
On history (mother will complain of),

 Feeling of drowsiness  Severe frontal headache

 General weakness  Thirst
 Severe epigastric pain  Visual disturbances
On observation

 Mother is restless
 Massive edema observed especially on the limbs or generalized with puffiness of the
face)
Vitals

 Rapid pulse
 Raised blood pressure of 160/110 and above
 Subnormal temperature lower than 35degrees
 Irregular respirations
General examination

 Skin will be cold and clammy

 Twitching of the muscles (muscle spasms)
Investigations

 Protenuria
 Oliguria
Management in the first 48 hours
This is an obstetrical emergency so act skill fully to save the life of the mother and baby

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Aims of management

– To decrease the re- occurrence of fits

– To save the life of the mother and baby
– To decrease the cardinal signs of eclampsia
In maternity center

 This mother is not supposed to be managed in the maternity center but,

 Admit temporarily, remove any thing that can injure the patient more preferably on a flat
surface
 Take quick history of the condition
 Take vital observations
 Give first aid treatment
First aid treatment
Anti convulsants: Magnesium sulphate or diazepam
Anti hypertensives: Nifedipine, aldomet
Antibiotics: Ampicillin 1 gm stat
Referral

 Write a referral note and escort the patient to hospital.

 Advise the driver to drive safely by avoiding unnecessary hooting
 Ears of the patient maybe padded to avoid her from hearing unnecessary noises.
In hospital

 Admit
 Take history
 Do observations, investigations, urinalysis to confirm protein in urine
 Prepare for doctors examination and inform doctor
Doctor’s management: Management will follow the aims of management as in maternity center.
Aims of management

 To decrease the re- occurrence of fits

 To save the life of the mother and baby
 To decrease the cardinal signs of eclampsia
Drugs
Anti hypertensive's: Hydralazine 5 mgs bolus then every 30 minutes and monitor B.P, reflexes
and respirations

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Anti convulsants: Magnesium sulphate 14 gms stat (4 gms i.v and 10gms i.m) then maintenance
dose of 5 gms 4 hrly
Antibiotics: Ceftriaxone 2gms start
Antidiuretics: Lasix 40mgs b.d to reduce the massive edema.
MANAGEMENT OF LABOUR
1st stage: Prepare for theatre
2nd stage: Usually vaginal delivery is expected if no contra indication ( delivery is usually assisted
mainly vacuum extraction)
3rd stage: Deliver by controlled cord traction (ergometrine is contraindicated
4th stage

 Will depend on the type of delivery

 Continue with observations
 Vitals
 Status of the uterus
 Bleeding per vagina
 Incision site if c/s
 Continue treatment as per chart (antibiotics, anti hypertensions, anti diuretics
Discharge
Discharge the mother if she delivered by S.V.D in 48 hours. If caesarian section continue with the
routine management.
Question 48

PLACENTA ACCRETA

Introduction

Placenta accreta is a life-threatening problem that is considered a high-risk pregnancy

complication.

Definition

This is an abnormal attachment or insertion of the placenta too deep the uterine, endometrium
beyond the basalis.

Pathophysiology

This abnormality results from an abnormal adherence of the placenta to the uterus with
subsequent failure of the placenta to separate after delivery of the fetus.

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Diagram showing morbid adherent of the placenta

Causes

Placenta accreta is thought to be related to abnormalities in the lining of the uterus, typically due
to scarring after a C-section or other uterine surgery.

This might allow the placenta to grow too deeply into the uterine wall.

Predisposing factors:

 Previous uterine surgery

 Placenta position
 Maternal age
 Previous childbirth
 Uterine conditions
 Asherman's syndrome

Diagnosis

Imaging tests.

Ultrasound or magnetic resonance imaging (MRI) to evaluate how the placenta is implanted in
your uterine wall.

Blood tests

A sample of blood for an otherwise unexplained rise in the amount of alpha feto protein a
protein that's produced by the baby and can be detected in the mother's blood. Such a rise has
been linked to placenta accreta.

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Clinical manifestation

 Not usually noticed not until during delivery.

 Persistent bleeding from material cord separation.
 Failure of placenta to detach.

Management

 Bed rest to help to continue with the pregnancy towards full term.
 When pregnancy has been monitored to term. Usually surgery is performed sparing the
uterus for next pregnancy.
 Unfortunately in most cases placenta accreta may be severe and hysterectomy may be
done.

Complications

 Hemorrhage due to manual attempts to detach

 Shock
 Hysterectomy
 Secondary infertility
 Depression

Question 49
1. a) What is integration of reproductive health services?
b) What are the reasons of IRHS?
c) What are the benefits of IRHS?
d) What are the rights of a client?

Solution

Definition

 Reproductive Health is the state of complete physical, mental and social wellbeing in all
matters relating to reproductive system [WHO 2009].
 Integration Reproductive Health Service Delivery: Is the way of providing complementary
reproductive health services to suite the needs of the client with the least inconvenience to
the client, there by promoting quality of care, acceptance, continuity and clients
confidence in the provider [Preservice IRHS Training content reference manual]

Definition/ Explanation

Reproductive health includes the following components:

 Maternal and newborn health

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  Family planning
 Prevention of unsafe abortion
 Management of reproductive tract infections including HIV/ AIDS
 Promotion of sexual health
 Integration means bringing together these components and establishing strong linkages
with other health care and related social services.

What are reasons of integrating Reproductive health?

1. To improve reproductive health

2. Clients seeking reproductive health services are generally the same men and women, The
service involve the same reproductive organs.
3. Some of the IRHS overlap for example reproductive counseling and management where
for instance , the condom is the only preventive method against STIs apart from
abstinence and as also a good family planning method if properly used.
4. Integration allows for earlier detection and prevention of STIs and HIV/AIDS.
5. Integration of services provides the opportunity to address the other reproductive health
needs of the clients which they otherwise might not seek care for.

All in all the main reasons for integration is to increase the effectiveness and efficiency of the
health system and to meet people‟s needs for accessible , acceptable, convenient, client
centered comprehensive care.

Part: C

What are the benefits of Integrating Reproductive health to Client and Service provider?

To the client

a) It saves time and is convenient.

b) It upholds the rights of the clients to information, comfort, continuity and confidentiality.
c) Addresses all the clientsreproductive health and needs.
d) Helps the clients to identify reproductive health risks and needs.
e) Improves client - provider relationship.
f) Increases clients satisfaction.
g) The Benefits of Integrating Reproductive health,

To the provider

a) It distributes duties better and makes sharing them more effective.

b) Makes resources accessible to every provider.
c) Spreads work load out over all services hours .

Part: D What are rights of a client?

Every client coming for reproductive health has right to the following:

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1. Information: To learn the benefits and availability of reproductive health services.
2. Access: To obtain services regardless of sex , colour , marital status or location.
3. Choice: To decide freely to receive reproductive health service.
4. Safety: To be able to receive safe and effective health service.
5. Privacy: to have a private environment during all steps of service delivery.
6. Rights of a client
7. Confidentiality: To be assured that any personal information will remain confidential.
8. Dignity: to be treated with consideration and attentiveness.
9. Comfort: to feel comfortable when receiving services.
10. Continuity: To receive reproductive health services for as long as needed.
11. Opinion: to express views on the services offered and receive respect for these views.

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 PEDIATRICS
Question 50

a) With the aid of a well labeled diagram, describe fetal circulation.

b) State the changes that occur at birth.
c) Give the functions of fetal circulation.

Introduction

The fetus develops its own blood from the inner cell mass and at no point does it mix with
maternal blood due to the presence of the four layers of the placenta:

 Syncytiotrophoblast
 Cytiotrophoblast
 Mesoderm
 Capillary wall

Definition

Fetal circulation is the flow of blood within the fetus.

In addition to the placenta and umbilical cord, there are 5 temporary structures involved;

Temporary structures

Umbilical vein: This leads from the umbilical cord to the under surface of the liver.

Ductus venosus: Carries blood from the umbilical vein to the inferior venacava.

Foramen ovale: A temporary oval opening between the two atria which allows the oxygenated
blood from the right atrium to the left atrium.

Ductus arteriosus: Carries blood from the pulmonary artery to the descending aorta.

Hypogastric arteries: Are branches of internal iliac arteries which carries deoxygenated blood to
the placenta for oxygenation and are called umbilical arteries when they enter the umbilical
cord.

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Description

The blood takes about half a minute to circulate and take the following course;

At the placenta, oxygenation takes place where the oxygenated blood starts to circulate through
the umbilical vein in the abdominal wall to the under surface of the liver.

This is the only vessel in the fetus which carries unmixed blood.

This large branch empties its oxygenated blood into the inferior vena cava where the mixing with
deoxygenated blood from the lower part of the body takes place.

At this point the blood is carried to the right atrium where most of it is directed across through the
foramen ovale to the left atrium.

Following its normal route, it enters the left ventricle and passes into the Aorta .

The heart and the brain receive supply of relatively well oxygenated blood since the coronary
and carotid arteries are the early branches from Aorta.

The arms also benefit via sub clavian arteries and this explains why they are more developed
than the legs at birth.

Deoxygenated blood from the head and upper limbs returns to the right atrium via the superior
venacava. This stream of blood crosses the one entering from inferior venacava and passes into
the right ventricle.

The two streams remain separate because of the shape of the atrium but there is mixing of about
25% of the blood allowing little amount of oxygen and nutrient to be taken to the lungs through
pulmonary artery.

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The remainder of the blood passes through the ductus arteriosus to the descending aorta where it
is distributed to the abdominal, pelvic organs and lower limbs but most of it is returned to the
placenta via hypogastric arteries for oxygenation and replenishment.

Changes that occur at birth

Are brought about by 4 factors

i. Exposure of the baby to external environment

ii. Establishment of respiration
iii. Crying of the baby
iv. Cutting of the cord

Exposure of the baby to external environment and establishment of respiration

 Soon after birth when the baby is exposed to the external environment, it takes its first
breath and expands its lungs. This is brought about by;
 A slight hypoxia due to the depression of placental circulation during uterine contractions.
 Changes in the sensory input from the quite confined uterus to the loud, bright and cold
place of birth.
 This makes blood to be drawn to the lungs through pulmonary arteries. This blood is then
collected and returned to the left atrium via pulmonary veins resulting in a sudden inflow
of blood.

Crying of the baby

 When the baby cries, it takes in oxygen making the lungs to expand and their vascular
field increases.
 This makes the blood that has been passing through the Ductus Arteriosus to the
descending aorta to flow through pulmonary arteries to the lungs for oxygenation.
 This causes the Ductus arteriosus to constrict and stop its function within 5 minutes after
birth and closes within 2 months anatomically.

Cutting of the cord

Due to cutting of the cord, placental circulations stops soon after birth and less blood returns to
the right side of the heart. In this way, the pressure in the left side of the heart becomes greater
than that in the right side and this results in the closure of the valve like foramen ovale

Ceasation of placental circulation

The ceasation of placental circulation also results in the collapse of the umbilical vein, ductus
venosus and hypogastric arteries

Major structures affected by the changes

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These changes will affect the 5 major temporary structures and they will change their functions
and names; as follows;

 Umbilical vein becomes ligamentum teres between the abdominal wall and the liver.
 changes
 Ductus venosus becomes the ligamentum venosum between the portal vein and the
inferior vena cava.
 Foramen ovale becomes fossa ovalis changes
 Ductus arteriosus becomes cardiac ligament
 The hypogastric arteries becomes urachus between the bladder and umbilicus

Functions of the fetal circulation

There are two major functions;

1. Transportation
 Nutrition
 Excretion
 Protection
 Respiration
2. Regulation of body temperature

Question 51

PRECIPITATE LABOUR

Definition:Labor of less than 3 hours, rate of cervical dilatation 5cm/hr or faster –nulliparas 10
cm/hr – multipara

OR

Emergency delivery without client‟s physician/ midwife Extreme rapid labor and delivery – result
from low resistance of soft part of the birth canal.

Assessment findings: As labor is progressing quickly, assessment may need to be done rapidly.

Client may have history of previous precipitous labor and delivery

Desire to push Observe status of membranes, perineal area for bulging and for signs of bleeding.

Pathophysiology

Results to hypertonic uterine contractions that are tetanic in intensity.

Hypertonic contraction pushing the fetus faster than normal (less than 3 hours)

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Signs/ symptoms:

 Intense Pain more than normal

 Increase heart ratepulse, body temp.
 Increased B/P
 Diaphoresis
 Nasal flaring
 Anxiety
 Restlessness
 Hypertonic contractions

Medical management:

Emergency delivery of an infant:

 Assess the client‟s affect and the ability to understand directions, as well as other resources
available (other physicians, nurses, auxiliary personnel).
 Stay with client at all times Pant and blow to decrease urge to push
 Do not prevent birth of baby
 Maintain sterile environment if possible
 Rupture membranes if necessary, slip overhead if possible
 Check around the infant‟s neck for a possible tight umbilical cord: if present, cord must be
clamped and cut before delivery.
 Support the perineum with a sterile towel as crowning occurs Use gentle aspiration with
bulb syringe to remove blood and mucus from nose and mouth.
 Deliver shoulder after external rotation, asking mother to push gently if needed Hold
baby in a head down position to facilitate drainage of secretions.
 Check mother for excess bleeding, massage uterus prn

Surgical management:Episiotomy as necessary especially in the nullipara

Nursing diagnosis:

Pain r/t force of hypertonic contractions

 Provide reassurance and instruct the woman in a calm, controlled manner.

 Provide nonpharmacologic pain relief such as massages.
 Instruct the pt. to assume Sim‟s lateral position; this would help to slow her labor down and
help prevent lacerations.
 Encourage pt. to pant at this time to prevent bearing down. Anxiety r/t process and stress
of labor and birth.
 Explain to pt. the process of labor and delivery

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  Providesupport as patient undergo labor.
 Approach patient in a calm and controlled manner.

Risk for injury (maternal and fetal) r/t hypertonic contractions

 Stay with client at all times Look out for crowning of fetus.
 Position pt. in Sim‟s lateral position as indicated to try to slow down contractions.
 Assist in delivery of baby and placenta
 Assist in performance of episiotomy

Risk of deficient fluid volume r/t hemorrhage 2° abrupt detachment of placenta 3° precipitous
delivery

 Observe pt. for signs of hemorrhage after delivery, and monitor for changes in vital signs
 Assist in giving medications that prevent haemorrhages as indicated, and start IV line as
ordered.
 Massage uterus prn.

Risk for infection

 Use aseptic technique in assisting with delivery and episiorrhapy.

 Maintain sterile environment if possible.
 Teach patient.
 Proper cleaning of area and wound site, if present.

Complications

 Maternal complication:
 Uterine rupture
 Laceration of the birth canal
 Amniotic fluid embolism
 Excessive Postpartum hemorrhage
 Fetal complications:
 Hypoxia
 Intracranial hemorrhage
 Unattended birth
 Sudden birth of infant

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Question 52

A four weeks old neonate is admitted on ward with the history of fast breathing chest
indrawing and stridor.
a) What would be your appropriate diagnosis for this neonate?
b) Explain the specific nursing care you would offer to this neonate in a hospital set up
in eight hours.
c) Mention any differential diagnosis for this condition.

Solution

Definition to the key terms

A neonate: - This is a new born baby within 28 days of life

A fast breathing: - This is when the breathing rate, rhythm, intensity and strength are abnormally
higher than normal I.e. more than 60 breathe per minute in neonate.

Chest indrawing: - This is when the intercoastal muscles and abdominal muscles on contraction
goes deeply inwards and takes some time to come back on relaxation.

Stridor: - This refers to a noisy breathing on inspiration.

a) The appropriate diagnosis of this neonate is severe neonatal pneumonia.

b) Severe neonatal pneumonia is a medical emergency.

Aims of the management

 To restore normal breathing.

 To save the life of this neonate.
 To prevent complications.

Admission: Since this is a medical emergency, the neonate has to be offered intensive
management from intensive care unit in neonatal unit in a quiet, well ventilated room.

Position: The baby is placed in a prop-up position on the mother‟s lap with support from the
mother and adequate warmth is provided for the neonate to exclude coldness which is a
predisposing factor.

Assessment: Quick assessment on this neonate which involves data collection or history taking
from the motherand physical examination.

Observation: The following observations are carried out and these include:-

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Vitals: Temperature, pulse, and respiration which are taken ¼ hourly, ½ hourly then hourly when
the baby is stabilising or as prescribed by the doctor.

Specific: These include oxygen saturation, weighing the baby, observing the skin colour for
cyanosis, level of consciousness, airway pattern, dehydration and chest movement.

General: This is carried out from head to toe example sign of anaemia, irritability of the baby,
inability to breast feed.

Immediate treatment/care:

Here immediate resuscitation has to done and these include: -

Airway clearances by the use of suction machine if any airway obstruction is realised.

Oxygen administration is done to correct on cyanosis. The amount given depends on the Doctors
directives.

Medications example bronchodilators like salbutamol nebulizer 0.1 mg/kg up to 2.5mg or as

prescribed by the Doctor in order to relax and dilate the respiratory tract.

I.V line has to be established and intravenous fluids/infusions are administered to correct on
dehydration since the baby cannot breast feed normally.

An NGT will be passed for feeding the baby and the mother is encouraged to express breast
milk.

Fever may be reduced by removing of extra clothes but not to leave the neonate uncovered.

Broad spectrum antibiotics are given in combination like I.V Gentamycin 2.5mg/kg body weight
and Ampicillin 30mg/kg body weight to combat bacterial infections.

Investigations:

Doctor orders for the following investigations to be carried out after thorough history taking, the
nurse ensures that the investigations are done. These include:-

 Blood sample for malaria parasite CBC, Grouping and cross matching in case of blood
transfusion, blood for culture and sensitivity
 Erythrocyte Sedimentation Rate (ESR).
 Oxygen concentration rate
 Throat swabs taken for culture and sensitivity to rule out other bacterial infections.

Medical treatment

The following drugs may be given. These include:

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Antibiotics: Appropriate antibiotics like I.V Gentamycin 2.5mg/kg body weight, I.V Ampicillin
30mg/kg body weight.

Antipyretics: Like Rectal Paracetamol 10mg/kg body weight or as prescribed to relieve pain
and to correct on fever.

Sedatives: Diazepam rectally 2.5mg/body weight

PCV: Pneumococcal conjugate vaccine can be started on since it is a first contact in a low dose
and repeated subsequently.

Resuscitation: I.V fluids continue as prescribed.

Specific nursing care

AIR WAY MAINTENANCE: Strict maintenance of airway is ensured throughout, these includes:

 Positioning the neonate in prop-up on the mother‟s lap.

 Proper suctioning of the mucus to prevent aspiration.
 Ensure oxygen therapy as much as it‟s needed.
 Passing of air way tube if deemed necessary.
 Administration of bronchodilators like salbutamol nebulizer.

Nutrition:

 NGT has to be established in situ for feeding this baby with expressed breast milk from
the mother.
 Exclusive breast feeding has to be ensured if the baby is able and stable.

Psychotherapy:

 Explain every procedure done on the child to the mother in simple terms.
 Other psychological care has to be maintained by a continuous reassurance given to the
mother by the nurse on the baby‟s condition and quality of general nursing care in order
to allay anxiety.

Medications:

The following drugs may be given. These include: -

 Appropriate antibiotics like I.V Gentamycin 2.5mg/kg body weight, I.V Ampicillin
30mg/kg body weight.
 Anti pyretics like Rectal Paracetamol 10mg/kg body weight or as prescribed to relieve
pain and to correct on fever.
 Sedatives Diazepam rectally 2.5mg/body weight.
 Oxygen therapy is to be continued.

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  Pneumococcal conjugate vaccine can be started on since it is a first contact in a low dose
and repeated subsequently.

Resuscitation:

 Maintain I.V fluids as prescribed.

 Monitor input and output using fluid balance chart to prevent circulatory overload.
 Encourage the mother to allow the baby to breast feed if able or expresses her breast
milk.

Hygiene:

 The skin has to be cared for by bathing the baby 4-6 hourly and hygiene of the mother is
ensured.
 Changing of napkin if soiled, soaking the bed linen and ensure that they are cleaned.

Handover: Report is made in written and verbal to inform the next nurse on duty on the progress
of the condition of the neonate and for any other ongoing management.

Note: Other general routine nursing care are given as for any other patient.

OR

Using nursing process approach method

NURSING NURSING PLANNING/RATIO IMPLEMENTATIO EVALUATION

ASSESSMENT DIAGNOSIS NALE N
 Fast breathing with  Ineffective  To improve  Placing the  Respiratory
respiration more breathing breathing neonate in distress was
than 70 breathe pattern pattern for propped up reduced up to
per minute. related to adequate position with 60b/m.
 Chest indrawing inflammatory ventilation within pillow on the  Nasal passage
 Presence of processes 30 minutes. mother‟s lap. was cleared and
wheezing  Removing neonate
nasal breathing
secretions by normally.
suctioning.
 Administration
of oxygen
therapy.
 Administering
medication as
prescribed like
antibiotics,
antipyretics
and
bronchodilator
s.
 Monitoring

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 neonate‟s
condition and
respiratory
status.
 Refusal to breast  Risk for  To promote  Establishing an  The mother
feed. deficient adequate I.V line and I.V reported the
 Reduced urine fluid volume hydration within fluid started. baby‟s ability
output. related to 1hr.  With holding to breast feed
 High body fever and  To maintain oral fluids to normally.
temperature of poor feeding fluid electrolyte prevent 
38.5oc balance. aspiration.
 Strict
monitoring of
input and
output to
prevent
circulatory
over load
 Drowsiness,  Fatigue  To promote  Provision of  The mother
weakness and related to adequate rest calm and reports the baby
lethargy increased throughout. quiet had a peaceful
work of environment sleep and
breathing. as much as responding well
possible. to stimuli.
 Ensure gentle
handling
during nursing
care and
organising the
care when the
child is awake
as well as not
disturbing the
sleep.
 Encouraging
the mother to
provide
warmth,
comfort and
safety.
 Maternal anxiety  Anxiety  To reduce the  Explaining  Mother looks less
and worries related to worries and each and anxious, calm
respiratory anxiety of the every and responds
distress and mother procedure positively by
hospitalisatio being carried asking questions
n of the on the baby in about care of
baby. a sample her baby.
language.
 Observing the
infant
regularly and
sharing the
information

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 with the
mother.
 Timely
administration
of the
prescribed
medications.
 Humble
response to all
the questions
asked by
mother.
 Involving the
mother always
in the infant
care.
 Poor feeding, body  Altered  To restore and  Passing nasal  The baby is able
weight of the baby. nutrition less provide gastric tube to take small
than body adequate and start amount of
requirement nutrition. nasal feeding. expressed
related to  Encouraging breast milk with
inability to the breast little difficulties.
breast feed feeding when
respiratory
distress is
reduced.
 Maintaining
cleanliness
and food
hygiene.
 Poor personal  Knowledge  To improve the  Instructing and  The mother is
hygiene deficit knowledge explaining to able to maintain
related to about the child the mother cleanliness and
care of the care teaching about the follows
baby and by simple health hygienic instructions
preventive teaching measures, carefully.
health warmth and
measures how to care
for the baby
while at home.
 Encouraging
regular check
up and
medical help
whenever
necessary.

c) The following are the differential diagnosis for the above condition: -
 Bronchitis (acute and chronic).
 Neonatal meningitis.

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  Unsuspected foreign body.
 Neonatal septicaemia.
 Asthma.
 Pulmonary oedema
 Pulmonary T.B
 Heart failure
 Pleural effusion.
 Lung fibrosis.
 Bronchiolitis.
 Laryngotracheitis.

Question 53
(a) Discuss the developmental milestones of a (3) year Bold toddler.
(b)Explain factors that affect growth and development in infancy period.

Solution
Development:
Refers to the kind of qualitative, gradual, orderly and durable changes people go through.
Milestones: Abilities achieved by children at certain ages.
Toddler: A child ranging from one year to three years.
Developmental milestones:These are abilities achieved by most children at certain ages.
They include the following; (1-3) years
At 1 year
Social and emotional
 Is shy or nervous with strangers
 Cries when mum or dad leaves
 Shows fear in some situations
 Has favorite things and people
 Puts out arm or leg to help with dressing
 Plays games i.e “peek- a- boo” and “pat-a-cake”
Language/ communication
 Responds to simple spoken requests.
 Uses simple gestures like shaking head “no” or waving “bye-bye”.
 Makes sounds with changes in tone.
 Says “maama” or “dada” and exclamations like “uhoh!”
 Tries to say words you say.
Cognitive (learning, thinking, problem-solving)
 Finds hidden things easily
 Copies gestures
 Bangs two things together

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  Starts to use things correctly ie drinks from a cup, brushes hair
 Looks at the right picture or thing when its named
 Puts things in a container, takes things out of a container
 Follows simple directions like “pick up the toy”

Movement/physical development
 Gets a sitting position without help.
 May stand alone
 May take a few steps without holding on

At one year and a half

Social and emotional
 May have temper tantrums
 May afraid of strangers
 Likes to hand things to others as play
 Shows affection to familiar people
 Plays simple pretend ie feeding a doll
 Points to show others something interesting
 Explores alone but with parent close by

Language / communication
 Says several single words
 Says and shakes head „no‟
 Points to show someone what he/she wants

Cognitive (learning, thinking, problem-solving)

 Knows what ordinary things are for i.e telephone, spoon, brush
 Points to get the attention of others
 Shows interest in a doll or stuffed animal by pretending to feed.
 Can follow 1-step verbal command without any gestures i.e sits when you say “sit down”.

Movement/Physical Development
 Walks alone
 May walk up steps and run
 Pulls toys while walking
 Can help undress herself
 Drinks from a cup
 Eats with a spoon

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At 2 years
Social and emotional
 Copies others especially adults and older children
 Gets excited when with other children
 Shows more and more independence
 Shows defiant behavior (doing what he has been told not to)
 Plays mainly besides other children, but is beginning to include other children i.e in chase
games.

Language/ communication
 Points to things or pictures when they are named.
 Knows names of familiar people and body parts
 Says sentences with 2-4 words.
 Follows simple instructions.
 Repeats words over hard in conversation.
 Points to things in a book.

Cognitive (learning, thinking, problem- solving)

 Finds things even when hidden under two or three covers
 Begins to sort shapes and colours
 Complete sentences in familiar books
 Follows 2-step instructions i.e “pick up shoes and put them in the closet”
 Names items in a picture book such as cat, bird, or dog.
 Might use one hand more than the other.

Movement/Physical Development
 Stands on tiptoe
 Kicks a ball
 Begins to run
 Climbs onto and down from furniture without help
 Throws ball overhand
 Makes or copies straight lines and circles
 Walks up and down stairs holding on

At 3 year
Social and Emotional
 Copies adults and friends
 Takes turns in games
 Shows concern for a crying friend

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  Understands the idea of “mine” and “his” or “hers”
 Shows a wide range of emotions
 Separates easily from mum and dad
 Dresses and undresses his/her self

Languages/Communication
Follows instructions with 2 or 3 steps
Can name most familiar things
Understands words like “in”, “on” and “under”
Names a friend
Says words like “I”, “me”, “we” and “you” and ,some plurals (cars,dogs,cats)
Caries on a conversation using 2-3 sentences

Cognitive [Learning, thinking, problem-solving]

 Copies a circle with pencil
 Turns book pages one at a time
 Understands what “two” means
 Does puzzles with 3 or 4 pieces
 Builds towers of more than 6 block

Movement/Physical Development
 Climbs well
 Runs easily
 Pedals a tricycle[3-wheel bike]
 Walks up and down stairs, one foot on each step.

[B].These factors are both negative and positive ones.

Social Economic Factors

Poverty contributes to poor nutrition of the mother leading to reduced nutrients in breast milk
hence poor growth and development while good nutrition would lead to proper growth and
development.

Weaning Practices: Poor and early weaning practices below 4-6 months of exclusive breast
feeding can decelerate the infant‟s growth and development.

Emotional disturbances of a mother: Worry may interfere with breast-feeding of the infant
leading to poor growth and development.

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Cultural influence: Mothers are limited from certain foods hence having a diet with fewer
nutrients for the child to depend on during breast-feeding resulting into poor growth and
development.

Child spacing: Poor child spacing leads to poor growth and development since infants are limited
from breast-feeding and other nutrients like poor and early weaning practices.

Sanitation: Poor sanitation habits predispose infants to different infections and diseases resulting
into poor growth and development.

Poor and inadequate medical supervision: Inadequate medical supervision affects growth and
development of an infant because underlying causes are not detected easily and treated.

Immunization: This prevents the child from the killer immunisable diseases that would have
affected growth and development.

Nutrition: Poor or inadequate nourishment of an infant leads to arrested development and

growth of the infant‟s brain and other organs leading to poor growth and development.

Infection: HIV/AIDS leads to poor growth and development of an infant.

Emotional support: Anew born baby starts with no knowledge and learns a great deal during
his/her first year of life, needs full emotional support i.e love, security, recognition of
achievements therefore lack of these can lead to poor growth and development.

Play: Encouraging playing helps in physical, mental and social development and growth and its
good for health therefore lack of play can lead to poor growth and development.

Language training: Should always talk and sing with their children and encourage them to talk
what they think and this promotes growth and development.

Growth monitoring: It helps in identifying problems and abnormalities that can affect the growth
and development of the baby.

Level of education of the mother: Educated mothers will be able to take care of their children
and feed them on good nourishing diet compared low social classes.

Provision of supplementary foods: Good and highly nourishing supplementary feeds promotes
proper growth and development.

Availability of food for the mother to feed on hence high nutrients in breast milk promotes good
growth and development.

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Birth conditions: Poor birth conditions like instrumental delivery can traumatize the infant‟s brain
leading to arrested growth and development of the infant.

Genetic factors: Inherited genes that run in families do also affect the child‟s growth and
development.

Environment: Cool and favorable environment to the infant promotes good growth and
development compared to harsh environments.
Political stability also contributes to proper growth and development.

Question 54
a).List ten abnormalities of pregnancy
b).What are the causes of fundal height bigger than the weeks of amenorrhea?
c).How do you diagnose multiple pregnancies?
d).Outline the specific complications of pregnancy and labour
Solution

Pregnancy refers to growth and development of a fertilized ovum from the time of conception
until the expulsion of the fully matured fetus.

An abnormality simply refers to the deviation from the normal.

Abnormalities of pregnancy include the following;

Abruptio placenta. This is bleeding due to separation of a normally situated placenta and may
occur as a result of physical trauma among other causes.

Placenta praevia. This is the bleeding from separation of an abnormally situated placenta usually
in the lower uterine segment. The placenta lies partially or wholly in the lower uterine segment.

Ectopic pregnancy. This is embedment of a fertilized ovum outside the uterine cavity. It most
commonly occurs in the oviducts but may also occur in the ovary, abdominal cavity or the cervical
canal but such cases are rare.

Multiple pregnancies. This is term used the describe pregnancy in which there is more than one
fetus in the uterus.

Chromosomal abnormalities. This is the formation of a zygote which may poses wither extra or
less number of chromosomes e.g. in down‟s syndrome, turners syndrome etc.

Hydatidiform mole. This is the gross malformation of the trophoblast (placenta). The chorionic villi
grow abnormally, are excessive and fill with fluid. This result in the chorionic villi filling the uterine
cavity rapidly.

Polyhydramnios. This is excessive amounts of liquor amnio or amniotic fluid which exceeds 1500
mls.

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Oligohydramnios. This is diminished amounts of amniotic fluids of less than 500 mls throught term.

Abnormal presentations. These are presentations that deviate from the normal cephalic (vertex)
presentations e.g. breach, face presentation, brow presentation.

Pregnancy induced hypertension i.e. pre-eclampsia and eclampsia.

b) Causes of fundal height bigger than weeks of amenorrhea

Fundal height refers to the distance between the top part of the uterus i.e. fundus and the top of
the symphysis pubis.

The causes of fundal height bigger than weeks of amenorrhea include the following;

Multiple pregnancies;This a term used to describe the development of more than fetus in the
uterus at the same time. These quickly occupy the uterine space pushing up the fundus faster.

Uterine fibroids;These are firm benign tumours of muscular and fibrous tissue that develop in the
uterus. Larger odematous fibroids accompanying presence of the baby quickly increase the
fundal height.

Macrosomia; This is the growth of the baby larger than average size in the uterus.

Polyhydrominos; .An excessive amount of amniotic fluid in pregnancy.

Placental abruption; This is the premature separation of normally situated placenta occurring
after the 22nd week of pregnancy resulting into heamorrhage.

Blood may be retained behind the placenta and forced into the myometrium infiltrating between
the muscle fibres of the uterus. The concealed hemorrhage causes uterine enlargement thus an
increase in fundal height.

Placenta praevia;This is a condition whereby the placenta is partially or wholly implanted in the
lower uterine segment on either the anterior of posterior wall.

Hydatidiform mole;This is gross malformation of the trophoblast (placenta), the chorionic villi
grow abnormally, are excessive and fill with fluid. Fluid filled chorionic villi that are excessive in
number and abnormally grow occupy much uterine space thus a marked increase in fundal height.

Certain congenital abnormalities; such as hydrocephalus. The abnormally large size of the fetal
head raises the fundal height above the weeks of amenorrhea.

False history of LNMP; (last normal menstruation period) i.e. if a mother gives the midwife a
later LNMP.

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c) Diagnosis of multiple pregnancies

(Signs and symptoms)

History taking

 Mother may tell you that she has a twin

 All minor disorders of pregnancy are exaggerated
 If mothers are multi-gravida, she complains that the pregnancy is growing too fast and
there is excess fetal
 Signs of anaemia pre-eclampsia may be present.
 Increased stride gravidulum.

On abdominal examination

 Abdomen l00ks bigger and round in shape

 Fundal height higher than weeks of amenorrhea
 If the head is presenting it feels smaller as compared to fundal height
 Two poles are felt
 There are many fetal movements all over the abdomen
 On auscultation will show two fetal sacs or two fetuses

In labour, if a mother comes in lab our with un diagnosised twin after delivery of first twin ,the
uterus returns to its former height.

When abdomen is palpated another fetus is felt and fetal heart is hard, on vaginal examination,
another bag of membrane is felt

d) Complications in pregnancy

Complications are health problems that occur in pregnancy and labour they can involve mother‟s
health, baby‟s health or both.

Bleeding if a mother is bleeding heavily and has severe abdomen pain and menstrual like cramps
and feels like is going to faint in the first trimester it could be a sign of ectopic pregnancy, heavy
bleeding with cramps may also be a sign of miscarriage in the first trimester or early second
trimester in contrast bleeding with abdomen pain in third trimester may indicate placenta
abruption.

Severe nausea and vomiting (hyperemesis gravid arum) it is very common to have some nausea
and vomiting when a mother is pregnant but if it gets severe then that is more serious if a mother
cannot eat or drink anything she runs a risk of becoming dehydrated and mulnourished which can
harm the fetus a causing water and electrolyte imbalances.

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High blood pressure: potential severe hypersensitive state of pregnancy are pre-clampsia which
is the same as gestational hypertension leading to proteinuria, oedema, BP 160/110 severe pre-
eclampsia.

Eclampsia (seizures in pre-eclamptic patient)

Help syndrome (heamolytic anaemia elevated liver enzyme and low platelets.

Deep venous thrombosis

Caused by pregnancy induced hyper-coagulability as a physical response to massive bleeding.

 Anaemia: level of heamoglobin are lower in 3rd trimester treatment varies according to
the severity of anaemia can be increasing by eating food containing iron or iron tablets or
by the use of parenderal iron.
 Infection: pregnant mothers are more susceptible to infections; this increased risk is caused
by increased immune tolerance in pregnancy to prevent an immune reaction against the
fetus.
 Preterm labour; Fetus born before Weeks of gestation can also be a result of pre-
eclampsia and eclampsia infections like malaria.

Complications in labour

 Fetal distress; is a condition in which the fetus runs short of oxygen or anything that
interferes with oxygen supply.
 Maternal distress; It is a condition in which the mothers condition has detororiated due to
stress of labour or it is simply maternal exhaustion.
 Vaginal fistula; this is when a hole develops between the vagina and the neighboring
cavities e.g. vesco vaginal fistula which is artificial opening between the urinary bladder
and the vagina.

Colevaginal fistula which is rare but may occur between pelvic abscess rapture into the posterior
vaginal fornix.Rectovaginal fistula; Is an artificial opening between the rectum and the vagina.

Uretovaginal fistula; is an opening between the ureters and the vagina.

 Uterine rapture; Complete or partial tears of the uterus associated with labour.
 Prolonged labour. This is when labour exceeds 24 hours.
 Placenta accreta; the placenta normally attaches to the uterine walls ( decidua) yet
normal embedment stops in the spongy layer of the deciduas.
 Amniotic fluid embolism; this is when the amniotic fluid enters the maternal circulation
through a tear in the membranes or placenta.
 Cord prolapsed; this is when the cord lies in front of the presenting part and membranes
are raptured.

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  Uterine Invasion; this is when the uterus turns inside out. It is classified according to;
(a) Severity
(b) Time
First degree; the body of the of the uterus reaches the internal os.
Second degree; the uterus reaches the internal os.
Third degree; Uterus, cervix and the vagina are inverted and visible outside.Time; acute
inversion occurs within the first 24 hours.
Sub-acute inversion; Occurs after 24 hours but within 4 weeks.
Chronic Inversion; Occurs after 4 weeks but it is rare.

Abnormal presentations;

E.g. breach, face and brow presentations. This is when the fetus presentation is not vertex.

Cephalo pelvic disproportion; Is whereby the foetus fails to pass through the pelvis safely due
to mechanical reasons.

 Postpartum haemorrhage; this bleeding from the birth canal after delivery of the
baby. The amount considered is 500ml or more or any amount that leads to
deterioration of the mother‟s condition.

Question 55
[a].Outline the physiological changes of pregnancy that can complicate cardiac disease.
[b].Outline the complications of precipitate labour
[c].Write all what you know about placenta accreta
Solutions

[a].Increased blood volume in terms of plasma will bring about cardiac overload and incase of
any heart disease can cause heart failure or cardiomegally.

Due to reduced hemoglobin during pregnancy i.e as a result of increased competition for raw
materials(irons, acids,&B12) because the mother and the fetus to produce red blood cells, the lean
muscle itself will not be able to get enough oxygen due to lowered oxygen carrying capacity
(H6).

Due to a reduction in BP during pregnancy as result of reduced cardiac contractility and

peripheral resistance by progesterone hormone, so in this case the heart will not be to pump
enough blood to meet its demands and other body organs tissues.

Hormonal changes

Increased production of progesterone hormone to during pregnancy leads to relaxation of

smooth/involuntary muscles hence reducing cardiac contractility and peripheral resistance which
contributes to lowering BP and increase of co-existing cardiac disease may cause heart failure.

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Increased aldosterone hormone by the adrenal cortex will increase sodium and water re-
absorption and potassium excretion which leads to an increase in fluid volume in the circulation
hence, cardiac overload (HTN).

During onset of labor an increase in production of oxygen hormone produced by posterior

pituitary gland increases the contractility of the uterine muscle and hence increased demand for
blood supply from heart immediately after the wearing off the contraction hence increased heart
activity.

Mechanical changes

Due to increased intra chest pressure resulting from upward compression of the diaphragm by the
increasing pressure in the abdominal contents which may be due to big baby ,multiple pregnancy,
polyhydrominous and the heart itself can be compressed or displaced lacking enough space for
contraction.

Immune changes

A reduction in immune system of a pregnant mother as a result of competition for raw materials
like proteins, vitamins which are used to produce antibodies , between the mother and the fetus,
in case of a cardiac disease e.g infective endocarditic, healing will be difficult and hence
complications.

Stoke volume increases 20% 20-24 weeks.

Increased preload is a problem for obstructive lesions (mitral or aortic stenosis) or ventricular
dysfunction.

NB. Stoke volume is the amount of blood pumped by left ventricle of the heart per beat.

b].complications of precipitate labour

Def:Labor of less than 3 hours, rate of cervical dilatation 5cm/hr or faster –nulliparas 10 cm/hr –
multipara
OR
Emergency delivery without client‟s physician/ midwife Extreme rapid labor and delivery – result
from low resistance of soft part of the birth canal.

Assessment findings: As labor is progressing quickly, assessment may need to be done rapidly
Client may have history of previous precipitous labor and delivery
Desire to push Observe status of membranes, perineal area for bulging and for signs of bleeding

MATERNAL

 Hemorrhage (PPH); this occurs due to failure of the uterus to contract after expulsion of
the fetus. (Uterine atony )
 Acute uterine inversion; occurs due to rapid expulsion of the fetus.
 Third degree tears

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  Ruptured uterus; It occurs due to strong uterine contractions in the process of expulsion of
the fetus.
 Retained placenta; comes as a result of uterine atony.
 Maternal distress/shock; due to haemorrhage or maternal exhaustion.
 Fistulae; which can be VVF or RVF due to force exerted on the pelvic floor muscles.
 Amniotic fluid embolism
FETAL

 Fetal distress
 Has a result of frequent strong uterine contractions.
 Cerebral haemorrhage or damage.
 Due to increased pressure on the fetus head.
 Fractures
 Due to rapid expulsion of the fetus.
Question 56

a) Define immunization
b) Explain the immunization schedule of Uganda according to UNEPI?
c) Explain how you can improve routine immunization services in your community to
avoid vaccine preventative diseases.
Solution

a) Definition: This is the process of developing a body defense mechanism following the
administration of a particular vaccine or exposure to specific antigen

The created antibodies protect the individual against specific disease

RELATED TERMS

Immunity: This is the body‟s ability to resist infection afforded by presence of circulating
antibodies

Vaccination: Means of producing an active immunity by using vaccines

Vaccine: A special preparation of an antigen material that can be given to produce an active
immunity

(b) Current immunization schedule

Age Vaccine Dosage Protects against Mode and site of Storage

administration temperature
At birth BCG Infants Tuberculosis Intra dermal ⁺20C - ⁺80C
0-11 months Right upper arm
0.05mls
11months
above 0.1mls

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 POLIO 0 2 drops Polio Oral
Mouths drops ⁺20C - ⁺80C
At 6wks Poli1 2 drops Polio Oral ⁺20C - ⁺80C
Mouth drops
DPT HepB 0.5 mls Diphtheria,tetanus. ⁺20C - ⁺80C
HIb 1 whooping cough Intramuscular
hepatitis H- Outer aspect of
influenza type B Left upper thigh
PCV 1 0.5mls Pneumococal virus Intramuscular ⁺20C - ⁺80C
Outer aspect of
Right upper thigh
At 10wks Polio 2 2drops Polio Oral ⁺20C - ⁺80C
DPT HEbB 0.5 mls Diphtheria,tetanus. Intramuscular ⁺20C - ⁺80C
HIB 2 whooping cough Outer upper
hepatitis H- aspect of left
influenza type B thigh
PCV 2 0.5mls Pneumococal virus Intramuscular ⁺20C - ⁺80C
outer aspect of
Right upper thigh
At 14wks Polio 3 2drops Polio Oral ⁺20C -⁺80C
DPT HEbB 0.5 mls Diphtheria,tetanus. Intramuscular ⁺20C -⁺80C
HIB 3 whooping cough outer upper
hepatitis H- aspect of Left
influenza type B thigh
PCV3 0.5mls Pneumococal virus Intramuscular ⁺20C -⁺80C
outer upper
aspect of Right
thigh
At 9months Measles 0.5mls Measles Subcutaneous ⁺20C -⁺80C
Left upper arm
Pregnant Tetanus 0.5mls Tetanus Intramuscular ⁺20C - ⁺80C
women or toxoids Upper arm
women of TT1&TT2
child (One month)
bearing TT2&TT3
age(15-44 (Six months)
years) TT3&TT4
(one year)
TT4&TT5
(one year)
There are many strategies that can be implemented to archive a high coverage of routine
immunization to avoid vaccine preventative diseases in the community and these include the following;

 Taking every opportunity to educate the community and the public about the need for
immunization together with the related advantages.
 Community mobilization by community health workers to get partially or non-immunized
children and link them to nearby clinics for immunization.
 Great efforts should be put in follow up of dropout rates to follow up children who have
had only one or two immunizations.

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  Immunization of children against measles on any opportunity during admissions to
hospital incase they were not immunized.
 Identifying underserved areas within the catchments area and visit them within the
outreach programs.
 Working together with village heath teams and groups like women groups to ensure that
all children get immunized.
 Improving accessibility to health facilities by infrastructural development of especially
roads and other means of transport to ensure that the community gets services when
needed.
 Creating more awareness and eradicating the myths about immunization in the community
this will improve on the turn ups for immunization.
 Organizing outreach programs to ensure that people with difficulty in accessing health
facilities get immunization services.
 Involvement of other relevant stake holders towards immunization programs e.g. political
leaders LC chairpersons other NGOs in collaboration with the government.
 Training more service providers about immunization programs to increase on the
manpower in the delivery of immunization services.
 Incase of out outbreaks massive immunization should be under taken for even un affected
areas.
 Improving on the quality of services by ensuring that all staffs are adequately trained in
immunization procedure and are sympathetic to mothers and talk to them encouragingly.

Question 57

(a) Define malnutrition

(b) Explain how a 3 year old Toddler with severe acute malnutrition can be managed in a
stabilization phase.
(c) Mention the possible complications this toddler is likely to get.

Solutions

(a) Malnutrition is a serious condition which occurs when a person‟s diet doesn‟t contain the right
amount of nutrients.

Or

Malnutrition is a condition that results when the body does not get the right amount of Vitamins,
minerals and other nutrients it needs to maintain health tissues and organ function.

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(b) Management

Aims of management

- Treat / prevent hypoglycaemia

- Treat / prevent hypothermia
- Treat / prevent dehydration
- Correct electrolyte imbalances
- Treat / prevent infections
- To correct micro nutrient deficiencies
- Achieve catch up growth
- Provide sensory stimulation and emotional support.
The management of severe acute malnutrition is can put into 10 steps for easy management and
good results

1. Treat / prevent hypoglycaemia

- Treat hypoglycaemia with glucose immediately

2. Treat / prevent hypothermia

– To treat hypothermia, Re-warm the child

– Keep Malnourished children warm day and night to prevent hypothermia

3. Treat / Prevent Dehydration

- Rehydrate more slowly than usual because too much fluid can kill
- Do not give IV fluids except in shock.
4. Correct electrolyte imbalances
- Give extra potassium and magnesium daily
- Limit sodium and (salt) intake.
5. Treat / Prevent infections.
– Give antibiotics routinely to all severely malnourished children to treat hidden infections

– wash hands to prevent cross infections.

6. Correct micro nutrient deficiencies

– Give extra Vitamin A, Zinc, Copper, Folic acid and multivitamins.

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 – Do not give iron until the child is in the Rehabilitation phase.

7. Start cautions feeding

– Give small amounts of F 75 daily every 3 hours day and night. F75 is a special; formula
designed to meet the needs of malnourished children.

8. Achieve catch-up growth.

– For rapid weight gain, give as much F100 or ready to use therapeutic food (RUTF) as a

child can eat 8 times daily.

F 100 and RUTF are high in energy and protein.

9. Provide sensory stimulation and emotional support

– Provide loving care, and stimulation to improve mental development.

10. Prepare for follow up after recovery.

11. – Teach mothers what to feed at home to help the child recover, malnourished children
need regular follow up to prevent relapse and death.
(C). Possible complications

- These are usually seen in marasmic and kwashiorkor children and include the following.

- Serious infections such as septicaemia, pneumonia, measles, gastro enteritis, tuberculosis,

aids often prespitate kwashiorkor.

– Hypoglycaemia due to loss of energy stores.

– Hypothermia

– Anaemia due to protein and iron deficiency.

- Electrolyte imbalances especially potassium deficiency and malabsoption.

– Tremors (Kwashi shakes)

– Sudden death.

NB: Hypoglycemia, hypothermia, infections and heart failure are the main causes of death in
severe malnutrition.

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Children with kwashiorkor have a low serum albumin, potassium, magnesium, sodium, copper and
zinc also low glucose, transferring and clotting factors.

Question 58

A Newborn baby of 5 days has been admitted with jaundice.

a) What may be the cause of that condition?

b) What will be the management of this condition?
c) How can neonatal jaundice be prevented?
d) What complications may follow this condition?

Definition of terms

Neonate is the period of life from birth to 28 completed days.

Neonatal jaundice is the yellow discolouration of the skin, sclera and mucous membrane of neonate
due to accumulation of excess bilirubin in the tissue and serum.

A bilirubin level of more than 85nmol/l (5mg/l).

Causes of neonatal jaundice

Causes of neonatal jaundice are classified into two i.e

 Physiological
 Pathological jaundice.

Causes of physiological jaundice

1. Increased red blood cell destruction and short lifespan of neonates RBC

Following birth HbA replaces HbF where the RBC is broken down into bilirubin and due to short
lifespan of about 80-90 days more are destroyed in a short time.

2. Enzymes deficiency: Relatively low activity of the enzyme glucuronyl transferase which normally
converts unconjugated bilirubin into conjugated bilirubin that can be excreted into the
gastrointestinal tract.

3. Increased enterohepatic reabsorption: Neonates lack the normal enteric flora that breaks down
conjugated bilirubin to urobilinogen resulting in relatively high reabsorption of bilirubin back into
circulation.

4. Decreased albumin binding capacity: The ability of a neonate to transportbilirubin to the liver
for conjugation is reduced because of lower albumin level.

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Causes of pathological jaundice

1. Increased production due to excessive RBC haemolysis in condition such as.

 Haemolytic disease of the newborn like rhesus disease( rhesus isoimmunisation)and ABO
incompatability
 Increased RBC membrane fragility like in spherocytosis and elliptocytosis.
 Sepsis which can lead to haemoglobin breakdown e.g TORCH.
 Enzyme deficiency e.g G6PD(glucose 6 phosphate dehydrogenase) deficiency ,pyruvate
kinase deficiency
 Globin synthesis defect like in sickle cell disease and alpha thalassemia e.g HbH disease
 Extravagated blood such as in cephalohaematoma.

2. Defective conjugation.

 Diminished of enzyme glucoronyl tranferase

 Metabolic and endocrine disorders that alter enzyme activity e.g. galactosemia , alpha 1
antitrypsin deficiency and hypothyroidism.
 Dehydration, starvation and hypoxia as oxygen and glucose are required for conjugation.
 Immature liver cells as in immaturity.
 Polycythemia is disease in which the blood volume occupied by RBC increases .
 Breast milk jaundice
 Alloimmunity is an immune response to foreign to an antigen from members of the same
species.
 Crigler najjar syndrome

3. Transport and excretion disorder.

 Hepatic obstruction caused by congenital abnormalities like biliary atresia and bile plugs
or absence of common bile duct.
 Drugs e.g. Chlorpromazine
 Umbilical cord sepsis lead to ascending thrombophlebitis .
 Idiopathic neonatal jaundice

Management of neonatal jaundice

Aims of management

– To identify and treat the cause

– To reduce the level of bilirubin.
– Prevent complication

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Actual management

Admission

The neonate is admitted in pediatrics ward or in an isolation if caused by sepsis.

Detailed history is taken

The mother and relative are reassured to allay anxiety.

Assessment

Physical examination of the baby is done i.e

 The extent of changes of the skin,

 Scleral colour
 Presence of dehydration
 Hypothermia
 Vomiting
 Irritability or high pitched cry

Signs of anaemia

 Vital observations (temperature, pulse ,respiration and blood pressure).

 Doctor is informed who will come and examine the neonate.

Investigation (test and studies)

 Complete blood count

 Serum bilirubin level
 Coombs test (direct and indirect )
 Recticulocyte count.
 ABO blood group and rhesus type.
 Peripheral blood smear
 Serum sample for TORCHES infection test.
 Enzyme assay like G6PD

Medical management

Doctor may order for the following drug.

 Antibiotics,eg IV Ampicillin 50mg/kg 12 hourly x5/7 and IV Gentamycin 5-10mg/kg

daily x 5/7
 Phenobarbitone 2mg/kg 8 hourly x 3/7

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  Intravenous line is put for rehydration with IV fluids in case of dehydration and for Drug
administration.

Phototheraphy

This prevents the concentration of un conjugated bilirubin in the blood from reaching levels where
neurotoxicity may occur.

The neonatal skin surface is exposed to high intensity light which photo chemically convert fat
unconjugated bilirubin in to water soluble conjugated bilirubin which can excreted in bile and
urine.

Phototherapy are of two types:

Conventional or fiberoptic light system

Conventional system

Fluoroscent lamps are used to deliver high intensity light and effectiveness depends on the wave
length.

Fiberoptic light system

Fiberoptic blanket (biliblanket) which deliver high intensity light with no ultraviolent thus ensuring
more skin is exposed to light.

Surgical management

Exchange blood transfusion.

 Excess bilirubin is removed from the neonate during exchange blood transfusion which is
indicated in ;
 Rh positive with direct combs test positive
 Cord blood Hb less than 15g/dl
 Rapid developing jaundiced with unconjugated bilirubin

Operation is done to correct the biliary atresia

Nursing care specific nursing care

 Keep the baby warm to prevent hypothermia.

 Oxygen therapy in case of difficulty in breathing and low oxygen saturation.
 Frequent breast feeding if unable to feed , a nasogastric tube is passed and neonate fed
with expressed breast milk.

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Observe the neonate for the following;

 The level of jaundice

 Signs of kernicterus
 Signs of hypothermia and hypoglycemia.
 Observe the feeding pattern

General nursing care

 Tepid sponging is done in case of pyrexia or hyperpyrexia.

 Nutrition, encourage the mother to breast feed the baby to prevent hypoglycaemia.
 Hygiene
o Change the babies clothings to ensure comfort and prevent sores
o Clean the baby
o Turning the baby to prevent pressure sores
 Bowel and bladder care
 Restrict visitor from entering the room to reduce risk of infection to neonate
 Psychotherapy, counsel /reassure the mother on the babys condition to allay anxiety.
 If the baby improves the plan for discharge is made and the baby discharged.

Mothers /caregiver education on discharge

 Adequate breast feeding

 Keep the baby warm
 Give prescribed medication prescribed
 Early morning sun bath not exceeding 5 minutes
 Take the baby for past natal care to receive immunisation at YCC.

iii) PREVENTION OF NEONATAL JAUNDICE

Prevention can be classified under the following

During antenatal

 Screening of the mothers for ABO blood group, rhesus factor and for genetic enzyme
deficiency like G6PD.
 Reduce the risk of premature by identification of high risk mothers and referral to hospital
for better management.
 Carry out TORCHES test and prompt treatment of the conditions if detected.
 Teach the mother care of the breast in preparation for lactation.
 Reduce the use of drugs like chloropromazine
 Administration
 Premarital counseling

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During labour

 Maintain aseptic technique to prevent infection

 Initiate breast feeding immediately.
 Immediate clamping and cutting of the cord to prevent polycythemia.

During puerperium

Prevention of infection to the baby

 Monitoring of the baby carefully within first 24 hours to detect any signs of jaundice.
 Frequent breast feeding of the baby as steady feeding will help increase babys weight
and development of the liver.
 Exposure of the baby to light,light reacts with bilirubin changing it into a form that does
not need to pass through the liver to be excreted.
 Checking of bilirubin level in the first day of life using bilirubinometer
 Scheduling atleast 1 follow up visit in the first week of life for the babies sent home from
the
 Hospital in 72 hours ( domicilliary care).
 Administration of anti Rhesus D to the mother within 72 hours after birth to prevent the risk
of hemolytic disease of the new borne in subsequent child birth.

Complications of neonatal jaundice

 Kernicterus; which is a brain damage due to very high levels of bilirubin.

 Cerebral palsy; it‟s a syndrome which shows permanent ,non-progressive and generalized
 Brain damage in children irrespective of the cause.
 Deafness due to damage of auditory centres in the brain
 Mental retardation
 Permanent liver damage
 Hypoglycemia may occur as the damaged liver may not convert glycogen to glucose for
the use.
 Disseminated intravascular coagulopathy.
 Acidosis
 Hypocalcaemia
 Cardiac failure
 Hydropfetalis/ icterus gravis

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Question 59
a) Outline the causes of postpartum haemorrhage.
b) Describe the management of a mother who starts bleeding soon after the delivery of the
body in health centre.

Solutions
Post partum hemorrhage is excessive loss of blood from genital tract of 500mls or more or any
amount that can make the mother‟s condition to deteriorate after the birth of the baby to the end
of puerperium.

Types include;

1. Primary PPH. This is the bleeding from genital tract within 24hrs of delivery. It‟s the common
obstetric hemorrhage.

2. Secondary PPH. This is abnormal bleeding from the genital tract from 24hrs of delivery until
6hrs post partum.

Causes

The cause of PPH can either be due to atonic uterus or retained placenta, trauma and
hypofibrogenaemia.

Causes of atonic uterus;

Atonic uterus is the failure of the myometrium at the placental site to contract and retract and
compress torn blood vessels and control blood loss by a living ligature action

Retained cotyledon or placental fragments, membranes or large clots.

Incomplete placenta separation interrupts the efficient contraction and retraction.

Precipitate labor because the uterus contracts vigorously during 1st and 2nd stage of labor to let
the muscles get sufficient opportunity to retract.

Prolonged labor leads to uterine inertia due to muscle exhaustion.

Polyhydrominious or multiple pregnancies leading to excessive stretching and therefore efficient.

Placental praevia; when the placental site is partially or wholly in the lower uterine segment
where the thinner musced.

Placenta abruptio; In this case, blood oozes between the muscle fibres interfering with effective
action.

General anaesthesia. There is powerful muscle relaxation to the uterine muscles plus loss of
contractile power.

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Mismanagement of 3rd stage of labor. Manipulation of the uterus, precipitate short irregular
contractions so that the placenta only partially separates and retraction is lost.

A full bladder. If the bladder is full on completion of 2nd stage, it interferes with uterine action.
Bladder becomes an abdominal organ and gives no room for the uterine to contract.

Traumatic PPH

This is when there is laceration of the perineum, vagina, cervix and uterus.

Bleeding usually occurs despite of a well contracted uterus, uppermost of the vagina, labium or
episiotomy.

Causes of traumatic PPH

 Large bodies
 Abnormal presentations.
 Face to pubis delivery.
 Pushing before full dilatation of the cervix.
 Manual removal of the placenta.

HYPOFIBRINOGENAEMIA/ COAGULATION DEFECTS

This is when there is reduction in fibrin content of blood resulting in clotting defects. In this
condition, the amount of fibrinogen in blood is reduced or absent leading to coagulation failure.

Causes of hypofibrinogenaemia

 IUFD if more than 3wks or more.

 Amniotic fluid embolism.
 Intra uterine infection including septic abortion
 Severe pre- eclampsia.

b) Management

Aims;

– To replace lost fluids and prevent shock.

– To arrest haemorrhage.
– To prevent infection.
– To prevent further complications.

Management is divided into 2 i.e. Preventive and active management.

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In Maternity centre

Its an obstetric emergency and teamwork is of paramount.

Call for help meanwhile do the following;

Receive the mother, put her on the examination bed and quick brief history and gentle general
examination is done.

Take vital observations i.e. TPRBP and reassure the mother if conscious and relatives.

Assess the blood loss and general condition of the mother.

 Empty the bladder.

 Rub up the fundus for a contraction.
 Give an oxytocin 10 IU I.M
 Feel for the contraction, deliver the placenta by CCT method.
 Expel the clots and the uterus is contracted.
 During this time, the mother‟s condition should be closely monitored.

Once the placenta is expelled, do the following;

 Swab the vulva and check for any tears, repair them if present as well as an episiotomy
and apply a perennial pad.
 Remove all the wet linen. Make the mother comfortable and keep her warm but don‟t
overheat.
 Continue ¼ hourly observations pulse, BP, state of the uterus, vaginal blood loss and color
of the mother.
 Measure the blood loss.
 Examine the placenta to confirm whether complete.
 If there is no bleeding and the placenta is retained, the mother is transferred to the
hospital as she is accompanied by the midwife.

If bleeding is not controlled and the placenta has not been expelled. This is an extreme
emergency where the mother‟s condition is in great danger of death. A midwife in a maternity
centre has to do manual removal of the placenta.

METHOD OF MANUAL REMOVAL

 Put the mother in lithotomy or dorsal position.

 If 2 midwives are present, an assistant cleans the vulva quickly with a suitable antiseptic.
 The midwife scrubs her hands in a very short time, puts on a sterile gloves.

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  Hold the cord with the left hand, the right hand in a cone making them as small as possible
with thumb in the palm and insert them into the vagina following the cord up to the
placenta, then locate the separation area of the placenta.
 Release the cord and support the uterus abdominally with the left hand.
 Separate the placenta by sliding the hand carefully from side to side.
 Keep the back of the hand against the uterine wall, gradually move up the uterus until it is
completely separated.
 Remove the placenta slowly withdrawing hand bringing the placenta.
 If in pieces, make sure that no bits remain on the other hand.
 Continue to provide counter traction to the fundus by pushing it in the direction of the hand
that is withdrawn.
 Examine the cavity to ensure that it is empty.
 Give I.V/I.M pitocin 10I.V or ergometrine 0.2-0.5mg.
 Give broad spectrum Abxs e.g. ampicillin 500mg-1g.
 Treat for shock.
 Transfer with a well written note and escort the mother to hospital.

In case the placenta is out and the mother is bleeding heavily,

 Rub the uterus & expel clots.

 Catheterize.
 Give ergometrine or oxytocin.
 Carry out bi-manual compression of the uterus or ballooning to control bleeding.

There are two types of uterus compression i.e. internal & external

Internal bi-manual compression

 It is an emergency method of controlling hemorrhage.

 Insert the hand into the vagina and form a fist.
 Place the fist into anterior fornix and apply pressure against the anterior wall of the
uterus.
 With the other hand press deeply into the abdomen applying pressure against the
posterior wall of the uterus.
 Maintain the compress until bleeding controlled and uterus is contracted.
 An antibiotic may be given especially 500mg-1g.
 Resuscitate the mother.
 Refer for further mgt in hospital.

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External bi-manual compression

 The uterus is rubbed until it contracts.

 The left hand holds the uterus up in such a way that fingers are at the back of the uterus.
 Then it‟s drawn upwards and forwards in the right hand.
 It is compressed btn hands.
 Ergometrine/ oxytocin is repeated.
 Then refer with a well written and verbal report and escort the mother to hospital.

If the cause is due to trauma, In case of 1st and 2nd degree tear of an episiotomy,

 Give an oxytocin and deliver the placenta if still in and expel clots.
 Repair them as quickly as in the maternity centre.
 Make sure the uterus is well contracted.
 Measure blood loss.
 Resuscitate the mother and refer to hospital for further mgt.

In case of 3rd and 4th degree tear, this is a hospital case;

 Give first aid mgt.

 Resuscitate the mother.
 Then transfer.

If the cause is due to hypofibrinogenaemia or coagulation disorders;

 Give vitamin K.
 Resuscitate the mother.
 And refer to hospital for further mgt.

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