Provid Basic First Aid and Emergency Care LG-19

Nursing Level III
NTQF Level III

Learning guide-19
Unit of Competence Providing Basic First aid and
Emergency Care
Module Title: Providing Basic First aid and
Emergency Care
LG Code: HLT NUR3 LO5 LG17
Module Code HLT NUR3 M04 0219
TTLM Code: HLT NUR3 M LO5 TTLM, 09

2019 V1
LO5. Apply basic patient/client

care
Nursing Level III Vision :01 Sep. 2019: Page 1 of 153

Copyright Info/Author: Federal TVET Agency
Instruction Sheet Apply basic patient/client care
This learning guide is developed to provide you the necessary information regarding the
following content coverage and topics –
Basic procedures
 Bed making
 Catheterization
 Insertion and removal of NG-tube
 Enema
 Specimen/sample collection
 Medication administration
 Body mechanics and patient transport
 Cold compression.
Basic patient care
 Oral care
 Care for pressure area
 Bed bath
 Back care
 Wound care
 Perineal care
 Car for fingernails and toe nails
 Car for hair
Advanced patient care
 Colostomy
 Tracheostomy
 Lumbar puncture
 Postural drainage
 Thoracentesis
 Paracentesis
 Patient care tools and equipment
This guide will also assist you to attain the learning outcome stated in the cover
page. Specifically, upon completion of this Learning Guide, you will be able to:
 Perform Bed making, catheterization, NG-tube insertion, vital sign taking, specimen
collection, medication administration, body mechanics and patient transport and
cold/cold compression.
 Provide oral care, pressure area care, bed bath, back care, wound care, perineal care,
caring for fingernails and toe nails and hair washing.

 Identify and provide advanced patient cares : colostomy care, tracheostomy care, lumbar
puncture, postural drainage, thoracentesis and paracenthesis.
Learning Instructions:
1. Read the specific objectives of this Learning Guide.
2. Follow the instructions described below 3 to 6.
3. Read the information written in the information “Sheet 1, Sheet 2, Sheet 3, Sheet 4,
Sheet 5, Sheet 6, Sheet 7, Sheet 8, Sheet 9, Sheet 10, and Sheet 12,in page 32,43, 51,
59, 67, 73, 112, 122, 126, 131, 141 and 146 respectively.
4. Accomplish the “Self-check 1, Self-check 2, Self-check 3, Self-check 4” , Self-check 5
Self-check 6, Self-check 7, Self-check 8, Self-check 9, Self-check 10, and Self-check
11,” in page 36, 46, 55, 63, 71, 95, 120, 123, 140, 144 and 179 respectively.
5. If you earned a satisfactory evaluation from the “Self-check” proceed to “Operation Sheet
1, Operation Sheet 2, Operation Sheet 2, Operation Sheet 3, Operation Sheet 4,
Operation Sheet 5, Operation Sheet 6, Operation Sheet 7, Operation Sheet 8, Operation
Sheet 9, Operation Sheet 10, Operation Sheet 11, Operation Sheet 12, Operation Sheet
13, Operation Sheet 14, Operation Sheet 15, Operation Sheet 16, Operation Sheet 17,
Operation Sheet 18, Operation Sheet 19, Operation Sheet 20, Operation Sheet 21,
Operation Sheet 22, Operation Sheet 23, and Operation Sheet 2 ” in page 38,
39,48,49,57,58,65,66,97,98,99,105,107,108 and 109 respectively.
6. Do the “LAP test” in page 41, 50 and 111 respectively
7. Ask from your trainer the key to correction (key answers) or you can request your trainer
to correct your work. (You are to get the key answer only after you finished answering
the Self-checks).
8. 7. Your trainer will give you feedback and the evaluation will be either satisfactory
or unsatisfactory. If unsatisfactory, your trainer shall advice you on additional work. But
if satisfactory you can proceed to Learning Guide #19

Information Sheet 1 Bed Making
Basic procedures
1.1. Bed making
 In most instances beds are made after the client receives certain care and when beds are
unoccupied. Unoccupied bed can be both open and closed.
Closed bed: is a smooth, comfortable and clean bed, which is prepared for a new patient
 In closed bed: the top sheet, blanket and bed spread are drawn up to the top of the bed
and under the pillows.
Open bed: is one which is made for an ambulatory patient are made in the same way but the top
covers of an open bed are folded back to make it easier of a client to get in.
Occupied bed: is a bed prepared for a weak patient who is unable to get out of bed.
Purpose:
1. To provide comfort and to facilitate movement of the patient
2. To conserve patient‟s energy and maintain current health status
Anesthetic bed: is a bed prepared for a patient recovering from anesthesia
⇒ Purpose: to facilitate easy transfer of the patient from stretcher to bed
Amputation bed: a regular bed with a bed cradle and sand bags
⇒ Purpose: to leave the amputated part easy for observation
Fracture bed: a bed board under normal bed and cradle
⇒ Purpose: to provide a flat, unyielding surface to support a fracture part
Cardiac bed: is one prepared for a patient with heart problem
⇒ Purpose: to ease difficulty in breathing
General Instructions
1. Put bed coverings in order of use
2. Wash hands thoroughly after handling a patient's bed linen Linens and equipment soiled which
secretions and excretions harbor micro-organisms that can be transmitted directly or by hand‟s
uniforms
3. Hold soiled linen away from uniform
4. Linen for one client is never (even momentarily) placed on another client‟s bed

5. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is gathered
for disposal
6. Soiled linen is never shaken in the air because shaking can disseminate secretions and
excretions and the microorganisms they contain
7. When stripping and making a bed, conserve time and energy by stripping and making up one
side as completely as possible before working on the other side
8. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to
strip bed
9. Make a vertical or horizontal toe pleat in the sheet to provide additional room for the clients
feet.
Vertical - make a fold in the sheet 5-10 cm 1 to the foot
Horizontal – make a fold in the sheet 5-10 cm across the bed near the foot
10. While tucking bedding under the mattress the palm of the hand should face down to protect
your nails.
Order of Bed Covers
1. Mattress cover
2. Bottom sheet
3. Rubber sheet
4. Cotton (cloth) draw sheet
5. Top sheet
6. Blanket
7. Pillow case
Note
 Pillow should not be used for babies
 The mattress should be turned as often as necessary to prevent sagging, which will cause
discomfort to the patient.
A. Closed Bed
• It is a smooth, comfortable, and clean bed that is prepared for a new patient

Essential Equipment:
• Two large sheets
• Rubber draw sheet
• Draw sheet
• Blankets
• Pillow cases
• Bed spread
B. Occupied Bed
Purpose: to provide comfort, cleanliness and facilitate position of the patients
Essential equipment:
• Two large sheets
• Draw sheet
• Pillow case
• Pajamas or gown, if necessary
Making a post operative bed:
 The entire bed need clean linen.
 Make the bottom of bed as you normally would.
 The post operative the bottom of bed as you normally would.
 The post operative bed usually requires a draw sheet under the client‟s hips. Usually
another draw sheet is placed under the client‟s heard.
 In some cases, top liners are simply tan-folded to the foot of the bed. In others, a full post
operative bed is made.
 To do this, put the top linens over the foundation, but do not tuck them in.
 Fold down the top as you would do in an occupied bed.
 Then fold the bottom of the linens up so that the fold is even with the bottom of the
mattress.
 Do not tuck the linen in. Fanfold the top linens to the side so that they lay opposite from
where you will place the client‟s stretcher.
 Alternatively, you may fanfold the linens to the foot of the bed.

 Leave a tab on top for easy grasping.
 Have two or more pillows available, but do not put them on the bed. Rational: A pillow
may be contraindicated for a client, usually the physician or charge nurse will determine
when it is safe for the client to have one.
 Be sure all furniture is out of the way.
 Be sure the call light is available, but keep it on the bed side stand until the client is in
bed. The call light cord is kept out of the way, to facilitate the transfer of the client to bed.
 Know what surgical procedure your client has had before you determine what special
equipment is needed.
 For the client‟s convenience and safety, make the following items available: tissue, an
emesis basin, a blood pressure cuff and stethoscope, a “frequent vital signs” flow sheet an
in take and output record, and an intravenous (IV) stand.
 Other items can be added according to the client specific requirements.
 Report to your charge nurse when you have completed the postoperative bed and
assembled the necessary equipment.
N.B. Procedures for other beds like cardiac bed are similar except the following points.
 For cardiac patient the bed need extra materials such as over bed table and additional
pillows
 Hard board is needed under the mattress for fracture bed.
Self-Check 1 Written Test
1. How many types of bed making do you know?

2. What is the function of bed the cradle?
3. Which types of bed are usually prepared for newly admitted patients?
4. What is the difference between open and closed bed?
5. Define occupied bed.
Note: Satisfactory rating - 8 points Unsatisfactory - below 8 points

You can ask you teacher for the copy of the correct answers.
Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
Short Answer Questions

1. ________________________________________________________________
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2. ________________________________________________________________
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3. ________________________________________________________________
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4. ________________________________________________________________
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5. ________________________________________________________________
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Operation Sheet 1 Closed Bed
Step 1Wash hands and collect necessary materials

Step 2: Place the materials to be used on the chair. Turn mattress and arrange evenly on the bed
Step 3: Place bottom sheet with correct side up, center of sheet on center of bed and then at the
head of the bed

Step 4: Tuck sheet under mattress at the head of bed and miter the corner
Step 5: Remain on one side of bed until you have completed making the bed on that side
Step 6: Tuck sheet on the sides and foot of bed, mitering the corners
Step 7: Tuck sheets smoothly under the mattress, there should be no wrinkles
Step 8: Place rubber draw at the center of the bed and tuck smoothly and tightly
Step 9: Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet
should be covered completely
Step 10: Place top sheet with wrong side up, center fold of sheet on center of bed and wide hem
at head of bed
Step 11: Tuck sheet of foot of bed, mitering the corner
Step 12: Place blankets with center of blanket on center of bed, tuck at the foot of beds and miter
the corner
Step 13: Fold top sheet over blanket
Step 14: Place bed spread with right side up and tuck it
Step 15: Miter the corners at the foot of the bed
Step 16: Go to other side of bed and tuck in bottom
Step 17: Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and
smoothening out all wrinkles, put pillow case on pillow and place on bed
Step 18: See that bed is neat and smooth
Step 19: Leave bed in place and furniture in order
Step 20: Wash hands
Operation Sheet 2 Occupied Bed
If a full bath is not given at this time, the patient‟s back should be washed and cared for
Step 1: Wash hands and collect equipment
Step 2: Explain procedure to the patient
Step 3: Carry all equipment to the bed and arrange in the order it is to be used
Step 4: Make sure the windows and doors are closed
Step 5: Make the bed flat, if possible

Step 6: Loosen all bedding from the mattress, beginning at head of the bed, and place dirty
pillow cases on the chair for receiving dirty linen
Step 7: Have patient flex knees, or help patient do so. With one handcover the patient‟s shoulder
and the shoulder hand over the patient‟s knees, turn the patient towards you
Step 8: Never turn a helpless patient away from you, as this may cause him/her to fall out bed
Step 9: When you have made the patient comfortable and secure as near to the edge of the bed as
possible, to go the other side carrying your equipment with you
Step 10: Loosen the bedding on that side
Step 11: Fold, the bed spread half way down from the head
Step 12: Fold the bedding neatly up over patient
Step 13: Roll dirty bottom sheet close to patient
Step 14: Put on clean bottom sheet on used top sheet center, fold at center of bed, rolling the top
half close to the patient, tucking top and bottom ends tightly and mitering the corner
Step 15: Put on rubber sheet and draw sheet if needed
Step 16: Turn patient towards you on to the clean sheets and make comfortable on the edge of
bed
Step 17: Go to the opposite side of bed. Taking basin and wash cloths with you, give patient back
care
Step 18: Remove dirty sheet gently and place in dirty pillow case, but not on the floor
Step 19: Remove dirty bottom sheet and unroll clean linen
Step 20: Tuck in tightly at ends and miter corners
Step 21: Turn patient and make position comfortable
Step 22: Back rub should be given before the patient is turned on his /her back
Step 23: Place clean sheet over top sheet and ask the patient to hold it if she/he is conscious
Step 24: Go to foot of bed and pull the dirty top sheet out
Step 25: Replace the blanket and bed spread
Step 26: Miter the corners
Step 27: Tuck in along sides for low beds
Step 28: Leave sides hanging on high beds

Step 29: Turn the top of the bed spread under the blanket
Step 30: Turn top sheet back over the blanket and bed spread
Step 31: Change pillowcase, lift patient‟s head to replace pillow.
Step 32: Loosen top bedding over patient‟s toes and chest
Step 33: Be sure the patient is comfortable
Step 34: Clean bedside table
Step 35: Remove dirty linen, leaving room in order
Step 36: Wash hands
LAP Test Practical Demonstration
Name: _____________________________ Date: ________________

Time started: ________________________ Time finished: ________________
Instructions: Given necessary templates, tools and materials you are required to perform the
following tasks within 2 hours.
Task 1: Perform closed bed
Task 2: Conduct Open bed
Task 3: Prepare occupied bed
Task 4: Prepare Cardiac bed

List of Reference Materials
1. First aid manual, Emergency procedures for everyone, at home, at work, at leisure, 8th edition
2. The Federal democratic republic of Ethiopia Minster of health, First Aid learning module
Addis Abeba, Ethiopia 2014
3. First Aid and Accident Prevention Lecture Note for Health Science Students the Carter Center,
the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education

Information Sheet 2 Catheterization
2.1 Urinary Catheterization

2.2 Definition of catheterization: Is the introduction of a tube (catheter) through the urethra into
the urinary bladder
• Is performed only when absolutely necessary for fear of infection and trauma
Note. Strictly a sterile procedure, i.e. the nurse should always follow aseptic technique
Catheter: is a tube with a hole at the tip
2.3 Types of Catheter
1. Straight (plain or Robinson)
2. Retention (Foleys, indwelling)
Selecting an appropriate catheter:
• May be made of
 ⇐ Plastic – for 1 week

 ⇐ Latex – 2-3 (rubber)
 ⇐ Silicon – for 2-3 month
 ⇐ Pelyvinylchloride (PVC) – 4-6
1. Select the type of material in accordance with the estimated length of the catheterization
period:
2. Determine appropriate catheter size
- are determined by diameter of lumen
- graded on French scale or number.
• Catheter size depends on the size of the urethral canal
⇐ # 8-10 Fr – children
⇐ # 14-16 Fr – female adults
⇐ # 18 Fr – adult male
NB. Fr= French Scale
3. Determine appropriate catheter length by the clients gender
• For adult male – 40 cm catheter
• For adult females – 22 cm catheter
4. Select appropriate balloon size
• 5 ml – for adults
• 3 ml – for children
2.4 Catheterization using a straight catheter
Purpose
• To relieve discomfort due to bladder distention
• To assess the residual urine
• To obtain a urine specimen
• To empty the bladder prior to surgery
Equipment
I. Sterile
• Kidney dish
• Galipot

• Gauze
• Towel
• Solution
• Lubricant
• Catheter
• Syringe
• Water
• Specimen bottle
• Gloves
II. Clean
• Waste receiver
• Rubber sheet
• Flash light
• Measuring jug
• Screen
2.5 Inserting a Retention (Indwelling) Catheter
Retention (Foley) Catheter
Contains a second, smaller tube throughout its length on the inside
– This tube is connected to a balloon near the insertion tip.
Purpose
• To manage incontinence
• To provide for intermittent or continuous bladder drainage and irrigation
• To prevent urine from contacting an incision after perineal surgery (prevent infection)
• To measure urine output needs to be monitored hourly

Instruction: Say True if the statement is correct and False if it was wrong
1. Catheterization is performed only when absolutely necessary for fear of infection and trauma.
(2 point)
2. Catheterization is the introduction of a tube (catheter) through the urethra into the urinary
bladder. (2 point)
3. Among the following which one is not include on the purpose of catheterization __ (2 point)
A. To relieve discomfort due to bladder distention
B. To assess the residual urine
C. To obtain a urine specimen
D. To empty the bladder prior to surgery E. None

Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
1. ________________________________________________________________
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________________________________________________________________
________________________________________________________________
2. ________________________________________________________________
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________________________________________________________________
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3. ________________________________________________________________
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Operation Sheet 3 Catheterization
Step 1: Prepare the client and equipment for perennial wash

Step 2: Position the patient – dorsal recumbent (pillows can be used to elevate buttocks in
females)
Step 3: Drape the patient.
Step 4: Perform perinea care
Step 5: Prepare the equipment
Step 6: Create a sterile field
Step 7: Drop the client with a sterile drape
Step 8: Clean the area with antiseptic solution.
Step 9: Lubricate the insertion tip of the catheter (5-7 cm in)
Step 10: Expose the urinary meatus adequately by retracting the tissue or the labia minora in an
upward direction – female
Step 11: Retract the fore skin of uncircumcised mal.
Step 12: Grasp the penis firmly behind the glans and hold straighten the down ward curvature of
vertical it go to the body – male hole the catheter 5 cm from the insertion tip
Step 13: Insert the catheter into the urethral orifice

Step 14: Insert 5 cm in females and 20 cm in males or until urine comes
Step 15: Collect the urine – for specimen (about 30 ml)
Step 16: Pinch previous leakage
Step 17: Empty or drain the bladder and remove the catheter
Step 18: For adults experiencing urinary retention an order is needed on the amount to urine to
be expelled
Operation Sheet 4 Retention (Indwelling) Catheter

Step 1: Explain the procedure to the patient
Step 2: Prepare the equipment like:
Step 3: Retention catheter
Syringe
⇐ Sterile water
⇐ Tape
⇐ Urine collection bag and tubing
Step 4: After catheter insertion, the balloon is inflated to hold the catheter in place with in the bladder.
Step 5: The out side end of the catheter is bifurcated i.e., it has two openings, one to drain the urine, the
other to inflate the balloon.
Step 6: The balloons are sized by the volume of fluid or air used to inflate them 5 ml – 30 ml (15
commonly) indicated with the catheter size 18 Fr – 5 ml.
Step 7: Test the catheter balloon
Step 8: Follow steps as insertion straight catheter
Step 9: Insert the catheter an additional 2.5 – 5 cm (1-2 in) beyond the point at which urine began to flow
(the balloon of the catheter is located behind the opening at the insertion tip) – this ensures that the
balloon is inflated inside the bladder and not in the urethra (cause trauma)
Step 10: Inflate the balloon with the pre filled syringe

Step 11: Apply slight tension on the catheter until you feel resistance: resistance indicates that the
catheter balloon is inflated appropriately and that the catheter is well anchored in the bladder
Step 12: Release the resistance
Step 13: Tape the catheter with tape to the inside of a females thigh or to the thigh or a body of a male
client
Step 14: Restricts the movement of the catheter and irritation in the urethra when the client moves
Step 15: When there is increased risk of penile scrotal excoriation
Step 16: Establish effective drainage
Step 17: The bag should be off the floor – the emptying spout does not become grossly contaminated
Step 18: Document pertinent data
Removal
Step 19: Withdraw the solution or air from the balloon using a syringe And remove gentl
Name: _____________________________ Date: ________________

Instructions: Given necessary templates, tools and materials you are required to perform the
following tasks within 2 hours.
Task 1: Perform Straight (plain or Robinson) chateterization
Task 2: Conduct Retention (Foleys, indwelling)
Task 3: Remove Retention (Foleys, indwelling)

Information Sheet 3 Insertion and removal of NG-tube
3.1 Clinical Indicators/Purpose for Nasogastric Tube insertion
Appropriate Nasogastric tube selection is dependent on the clinical indication for placement
3.2 Decompression indicators
 Post-operative Ileus
 Increased abdominal distention
 Abdominal Pain
 Vomiting associated with any of the above indicators mentioned.
Other indicators
 Provide a route for short term Enteral Nutrition.
 Administration of medication
Correct Tube Insertion
3.3. Gastric Content Drainage/Decompression Tube selection
Roche Ryles tubes (Sizes 8-16 Fr) are most commonly used for gastric decompression and
aspiration of gastric contents
They are not recommended for enteral feeding (> 1 week) as they are associated with the
following complications
 Rhinitis
 Oesophagitis
 Gastritis

3.4. Enteral Feeding Tube selection
 Fine bore NGT can be inserted to provide a route for enteral nutrition and hydration of
patients.
3.5 Nasogastric tubes commonly used for enteral feeding include:
 Flexiflo
 Flocare
 Corflo
These provide access for short term enteral nutrition (up to 6 weeks)
- For mid to long term (>6weeks) it is recommend that a Percutaneous Endoscopic
gastrostomy (PEG) tube be considered.
- If a Post Pyloric Tube insertion is required, the surgical /medical team responsible for the
patient should contact the Radiology department and send the appropriate referral
Note:
- Seek clinical guidance from senior medical, nursing staff and dietitian with regards to the
recommended size tube for the patient. This can range from 8-16 Fr.
- Ensure gauge is appropriate for viscous medication administration if required.
- A weighted enteral feeding tube tip gravitates preferentially to the posterior oropharynx,
pointing towards the oesophagus reducing the potential risk of misplacement.
- An oral syringe (catheter tip syringe) must be used with medication administration through a
nasogastric tube
3.6 Checking the Correct Positioning of NGT
1. Correct Tube position must be checked:
 On insertion and
 Before every feed or medication administration
 If there is suspected displacement following vomiting, excessive coughing or accidental
dislodgement by patient
2. Confirmation of gastric contents must be confirmed using ph indicator strips. Auscultation of
air insufflated via the nasogastric tube should not be used and litmus paper is not longer
recommended)

3. Confirmation of correct position must be documented in the clinical notes.
4. Enteral Feeding Tube considerations
 All nasogastric enteral feeding tubes (Fine bore and wide bore tubes) must have correct
placement confirmed by an X-ray before administering any feed
 All patients that require enteral feeding must be referred to the Dietitian prior to
commencement of enteral feeding.
3.7 Complication Considerations
1. If dislodged the NGT must not be re-inserted in patients who have received an:
 Oesophagectomy
 Gastrectomy
In this case Nursing staff are to notify senior medical staff immediately
2. Other potential complications following insertion of a NGT include:
 Oesophageal Perforation
 Aspiration
 Fistula Formation
 Knotting/Kinking of the tube

3.8 Contra indications
 Reduced LOC (Ward Level)
 Maxillo-Facial Disorders/Surgery
 Fractured Skull
 Disorders of the nasopharynx/oesophagus
3.9 Insertion Equipment
 Lubricant (water based)
 Baker-PHIX pH Indicator Strips 2.0 – 9.0 (0.5 pH graduation)
 Skin prep, Flexi-Trak or Naso-Fix securing dressing
 Tissues and towel
 Disposable pad
 White Plastic Container
 50mL catheter or Luer lock syringe (if introducer to remain in for X-ray purposes)

 Non sterile gloves
 Apron
 Continuous drainage bag and holder
 Naso-gastric Pack
 Local anaesthetic spray (needs to be prescribed on QMR0004 Form)
 Permanent marker pen
 Glass of water & a straw
Removal of NG tube
Equipment
 Non-sterile Gloves
 Disposable Apron
 Tissues, Protective Sheet
 White Plastic Container
 Clinical Waste Bag
 „Remove‟ Swabs

1. Define NG tube (2 Points)

2. List indication of NG tube insertion (4 Points)
3. Mention indicators of correct placement of NG tube (4 Points)
4. Describe complication of NG tube insertion (4 Points)
5. Describe contraindication of NG tube insertion (4 Points)

Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
1. ________________________________________________________________
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________________________________________________________________
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2. ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
3. ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
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4. ________________________________________________________________
________________________________________________________________
________________________________________________________________
5. ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Operation Sheet 5 Insertion and removal of NG-tube
Steps 1 Ascertain the need for the nasogastric tube, i.e. feeding or aspiration/decompression. Verify
the order for tube placement – with medical staff/senior nursing staff before proceeding.
Identify the correct patient, explain and discuss the procedure to the patient forewarning
Steps 2 them that they may experience some discomfort.
Agree on a signal that the patient can use to stop during the procedure e.g. raising hand
Steps 3 Position the patient in an upright position in a bed or a chair.
This position assists swallowing and increases the oesophageal opening. Support the head
with pillows and assemble equipment.
Steps 4 Check the patient‟s nostrils are patent by asking the patient if possible to sniff with one
nostril closed. Repeat with the other nostril.
(Apply local anaesthetic spray if charted)
Steps 5 Measure the length of the tube to be inserted and mark by placing the end of the tube at the
tip of the patient‟s nose and then extend the tube to the earlobe and 5cm past the
xiphisternum.
Lubricate tip of tube (3-4cms) with a reasonable coating of lubricating gel. If possible ask
patient to have a sip water to lubricate pharynx.
Steps 6 Gently, insert the lubricated tube into the selected nostril.
Using the natural curve of the NGT facing downward, slide the tube backwards and inwards
along the floor of the nose to the nasopharynx. If any obstruction is felt, withdraw the tube
and try again in a slightly different direction or use the other nostril. Resistance will be
encountered at the posterior wall of the nasopharynx. Once past the nasopharynx rotate tube
between fingers so that natural curve should be running along posterior pharyngeal wall.
Ask patient to put their head as forward as possible – chin to chest (neck flexed)
Steps 7 As the tube passes down the oropharynx, instruct patient to swallow (if appropriate) sips of
water, advancing the tube gently with each swallow.
Insert tube as far as marked length.
Note: Do NOT force the tube.
Seek Medical or Specialist Nursing assistance if you are unable to insert the tube.
Steps 8 Aspirate contents of the stomach or obtain immediate drainage with a syringe and test
acidity using the Ph indicator. Ensure the pH is < 5.5
If aspirate cannot be obtained, inject 30 mL of air and try again.
Step 9 If still unable to aspirate fluid, move patient onto left side so gastric contents are sitting
within the greater curvature and wait 30 minutes before trying to aspirate again.
Steps 10 If there are any doubts regarding the placement of the tube or if the patient‟s condition
causes concern such as
-effective cough, swallow reflex
An X-ray must be obtained to confirm placement.

Steps 11 Measure the external length of the tubing and document in clinical record. Tape tube to
patient‟s nose to secure it.
For patients with an increased risk of accidental removal, tape the tube behind the patient‟s
ear and secure down the neck.

Attach a spigot or a continuous drainage bag if ordered (ensure that the bag is placed below
stomach level).
Steps 12 Educate patient re securement to avoid accidental removal. Document the insertion of the
tube, stating time, reason for insertion and volume of aspirate in the patient‟s clinical record
Operation Sheet 6 Removal of NG-tube
Step Action
Step 1 Verify verbal/written order for removal of NGT from medical team
responsible for patients care.
Identify the correct patient, explain and discuss the procedure to the patient,
ensuring privacy and adequate lighting.
Step 2 Wash hands and prepare equipment required as per local infection control
policy Volume 10.
Step 3 Ensure that patient is placed in an upright in a bed or a chair, supporting the
head with pillows.
Step 4 Aspirate the gastric contents before removal then flush NGT with 10-20mls
of air (this will dispel any residual fluid that may be located at the distal end
of the tubing)
Step 5 Remove securing adhesive strips or Naso-Fix dressing.
Step 6 Instruct patient to take a deep breath and hold, this will close off the glottis
and reduce the risk of potential aspiration whilst removing the tubing.
Step 7 While removing the tubing, pinch the tubing, this will prevent any contents
in the tubing from draining into the patient‟s throat.
Step 8 Observe nasal mucosa for signs of trauma or ulceration, ensuring patient is
comfortable post removal of tubing.
Step 9 Document procedure on Fluid balance chart and in clinical record
Video: https://www.youtube.com/watch?v=_bfyhbrdohU

Information Sheet 4 Enema
4.1 Enema: is the introduction of fluid into rectum and sigmoid colon for cleansing, therapeutic
or diagnostic purposes.
Purpose:
• For emptying – soap solution enema
• For diagnostic purpose (Barium enema)
• For introducing drug/substance (retention enema)
Solution used:
1. Normal saline
2. Soap solution – sol. Soap 1gm in 20 ml of H2O
3. Epsum salt 15 gm – 120 gm in 1,000 ml of H2O
Mechanisms of some solutions used in enema
1. Tap water: increase peristalsis by causing mechanical distension of the colon.
2. Normal saline solution
3. Soap solution: increases peristalsis due to irritating effect of soap to the lumenal
mucosa of the colon.
4. Epsum salt: The concentrated solution causes flow of ECF (extra cellular fluid) to the
lumen causing mechanical distension resulting in increased peristalsis.
4.2 Classified into:
• Cleansing (evacuation)
• Retention
• Carminative
• Return flow enema
Cleansing enema
Kinds:
1. High enema
 �Is given to clean as much of the colon as possible
 �The solution container should be 30-45 cm about the rectum
2. Low enema

 �Is administered to clean the rectum and sigmoid colon only
Guidelines
 Enema for adults are usually given at 40-43oc and for children at 37.7 oc
 Hot – cause injury to the bowel mucous
 Cold – uncomfortable and may trigger a spasm of the sphincter muscles
The amount of solution to be administered depends on:
 Kind of enema
 The age of the person and
 The person ability to retain the solution
Age Amount
 18 month 50-200 ml
 18 mon-5 yrs 200-300 ml
 5-12 yrs 300-500 ml
 12 yrs and older 500-1,000 ml
 The rectal tube should be appropriate: is measured in French scale
Age Size
 Infants/small child 10-12 fr
 Toddler 14-16 fr
 School age child 16-18 fr
 Adults 22-30 fr
Purpose
 To stimulate peristalsis and remove feces or flatus (for constipation)
 To soften feces and lubricate the rectum and colon
 To clean the rectum and colon in preparation for an examination. E.g. Colonoscopy
 To remove feces prior to a surgical procedure or a delivery
 For incontinent patients to keep the colon empty
 For diagnostic test
E.g. before certain x-ray exam – barium enema
Before giving stool specimen for certain parasites

Retention Enema
 Administration of solution to be retained in rectum for short or long period
 Are enemas meant for various purpose in which the fluid usually medicine is retained in
rectum for short or long period
– For local or general effects
E.g. oil retention enema
Antispasmodic enema
1. Principles:
 Is given slowly by means of a rectal tube
 The amount of fluid is usually 150-200 cc
 Cleansing enema is given after the retention time is over
 Temperature of enema fluid is 37.4 c or body
(Return flow Enema) Harris fluid
Purpose
 To supply the body with fluid.
 To give medication E.g. stimulants – paraldehyde or antspasmodic.
 To soften impacted fecal matter.
Other equipment is similar except that the tube for retention enema is smaller in width.
Procedure
 Similar with the cleansing enema but the enema should be administered very slowly and
always be preceded by passing a flatus tube
Note
1. Most medicated retention enema must be preceded by a cleansing enema. A patient must
rest for ½ hrs before giving retention enema
2. Elevate foot of bed to help patient retain enema
3. The amount of fluid is usually 150-200 cc
4. Temperature of enema fluid is 37.4 oc or at body
5. Kinds of solution used to supply body with fluid are plain H2O, normal saline, glucose
5% soda bicarbonate 2-5%
6. Olive oil 100-200 cc to be retained for 6-8 hrs.‟ is given for server constipation

Rectal Washout (Siphoning Enema)
(Colon irrigation or colonic flush)
- Also called heterolysis
- Is the process of introducing large amount of fluid into large bowel for flushing purpose
and allow return or wash out fluid?
Purpose
• To prepare the patient for x-ray exam and sigmoidoscopy
• To prepare the patient for rectum and color operation
Solution Used
 Normal saline
 Soda-bi-carbonate solution (to remove excess mucus)
 Tap water
 KMNO4 sol. 1:6000 for dysentery or weak tannic acid
Note:
 The procedure should not take > 2 hrs
 Should be finished 1 hr before exam or x-ray – to give time for the large intestine to
absorb the rest of the fluid
 Give cleansing enema ½ hr before the rectal wash out
 Allow the fluid to pass slowly
Amount of solution
 5-6 liters or until the wash out rectum fluid becomes clear

1. Enema will be provide for the purpose of all except ____ (3 point)
A. For emptying B. For diagnostic purpose

C. For introducing drug D. None
2. Among the following which one is not include in classification of Enema (3 point)
A. Cleansing (evacuation) B. Retention
C. Carminative D. None
3. During provision of enema the amount of solution to be administered depends on (3 point)
A. Cleansing (evacuation) B. Retention
C. Carminative D. None
4. List purpose of providing enema (5 point)

Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
1. ____________________

2. ____________________
3. _____________________
4. ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________________________________________

Operation Sheet 7 Cleansing Enema
Step 1: Inform the patient about the procedure

Step 2: Put bed side screen for privacy
Step 3: Attach rubber tube with enema can with nozzle and stop cock or clamp
Step 4: Place the patient in the lateral position with the Rt. leg flexed, for adequate exposure of
the anus (facilitates the flow of solution by gravity into the sigmoid and descending color, which
are on the side Step 5: Fill the enema can which 1000 cc of solution for adults
Step 6: Lubricate about 5 cm of the rectal tube – facilities insertion through the sphincter and
minimizes trauma
Step 7: Hung the can = 45 cm from bed or 30 cm from patient on the stand
Step 8: Place a piece of mackintosh under the bed
Step 9: Make the tube air free by releasing the clamp and allowing the fluid to run down little to
the bed pan and clamp open – prevents unnecessary distention
Step 10: Lift the upper buttock to visualize the answer
Step 11: Insert the tube
�7-10 cm in an adult smoothly and slowly
�5-7.5 cm in the child
�2.5-3.75 cm in an infant
Step 12: Raise the solution container and open the clamp to allow fluid to flow
Step 13: Administer the fluid slowly if client complains of fullness or pain stop the flow for 30”
and restart the flow at a slower rate
– decreases intestinal spasm and premature ejection of the solution
Step 13: Do not allow all the fluid to go as there is a possibility of air entering the rectum or
when the client cannot hold anymore and wants to defecate, close the clamp and remove the
rectal tube from the anus and offer the bed pan.
Step 14: Remove bed pan and clean the rectal tube

Operation Sheet 8 Rectal Washout (Siphoning Enema)
Step 1: Insert the tube like the cleansing enema

Step 2: The client lies on the bed with hips close to the side of the bed (client assumes a right
side lying position for siphoning)
Step 3: Open the clamp and allow to run about 1,000 cc of fluid in the bowel, then siphon back
into the bucket
Step 4: Carry on the procedure until the fluid return is clear
Information Sheet 5 Specimen Collection

5.1 Introduction: Specimen collection refers to collecting various specimens (samples), such as,
stool, urine, blood and other body fluids or tissues, from the patient for diagnostic or therapeutic
purposes. Various types of specimen collected from the patient in the clinical settings, either in
outpatient departments (OPD) or in-patient units, for diagnostic and therapeutic purposes. These
includes, stool, urine, blood and other body fluid or tissue specimens.
5.2 General Considerations for Specimen Collection
When collecting specimen, wear gloves to protect self from contact with body fluids.
1. Get request for specimen collection and identify the types of specimen being collected and the
patient from which the specimen collected.
2. Give adequate explanation to the patient about the purpose, type of specimen being collected
and the method used.
3. Assemble and organize all the necessary materials for the specimen collection.
4. Get the appropriate specimen container and it should be clearly labeled have tight cover to seal
the content and placed in the plastic bag or racks, so that it protects the laboratory technician
from contamination while handling it.
• The patient's identification such as, name, age, card number, the ward and bed number (if in-
patient).
• The types of specimen and method used (if needed).
• The time and date of the specimen collected.
6. Put the collected specimen into its container without contaminating outer parts of the container
and its cover.
All the specimens should be sent promptly to the laboratory, so that the temperature and time
changes do not alter the content.
A. Collecting Stool Specimen
Purpose
• For laboratory diagnosis, such as microscopic examination, culture and sensitivity tests.
Equipments required
 Clean bedpan or commode

 Wooden spatula or applicator
 Specimen container
 Tissue paper
 Laboratory requests
 Disposable glove, for patients confined in bed
 Bed protecting materials
 Screen
B. Collecting Urine Specimen
Types of urine specimen collection
1. Clean voided urine specimen
(Also called clean catch or midstream urine specimen)
2. Sterile urine specimen
3. Timed urine specimen
• It is two types
Short period → 1-2 hours
Long period → 24 hours
Purpose
• For diagnostic purposes
- Routine laboratory analysis and culture and sensitivity tests
Equipments Required
• Disposable gloves
• Specimen container
• Laboratory requisition form (Completely filled)
• Water and soap or cotton balls and antiseptic solutions (swabs).
For patients confined
• Urine receptacles (i.e. bedpan or urinals)
• Bed protecting materials
• Screen (if required)
5.3 Collecting a Sterile Urine Specimen

Sterile urine specimen collected using a catheter in aseptic techniques (The whole discussion for
this procedure presented on the catheterization part)
5.4 Collecting a Timed Urine Specimen
Purpose
• For some tests of renal functions and urine compositions, such as:- measuring the level of or
hormones, such as adrenocortico steroid hormone creatinine clearance or protein quantitation
tests.
Equipments Required
• Urine specimen collecting materials (usually obtained from the laboratory and kept in the
patient's bathroom.)
• Format for recording the time, date started and end, and the amount of urine collected on each
patient's voiding during the specified period for collection.
C. Collecting sputum specimen
Sputum is the mucus secretion from the lungs, bronchi and trachea, but it is different from saliva.
The best time for sputum specimen collection is in the mornings up on the patient‟s awaking
(that have been accumulated during the night). If the patient fails to cough out, the nurse can
obtain sputum specimen by aspirating pharyngeal secretion using suction.
Purpose
Sputum specimen usually collected for:
• Culture and sensitivity test (i.e. to identify the
microorganisms and sensitive drugs for it)
• Cytological examination
• Acid fast bacillus (AFB) tests
• Assess the effectiveness of the therapy
Equipments Required
• Specimen container

• Laboratory requisition form
• Mouth care (wash) tray
D. Collecting Blood Specimen
The hospital laboratory technicians obtain most routine blood specimens. Venous blood is drown
for most tests, but arterial blood is drawn for blood gas measurements. However, in some setting
nurses draw venous blood.
Purpose
Specimen of venous blood are taken for complete blood count, which includes
• Hemoglobin and hemotocrit measurements
• Erythrocytes (RBC) count
• Leukocytes (WBC) count
• Differential counts
Equipment
• Sterile gloves
• Tourniquet
• Antiseptic swabs
• Dry cotton (gauze)
• Needle and syringe
• Specimen container with the required diluting or preservative agents, for example:
anticoagulant.
• Identification/ labeling: name, age address, etc.
• Laboratory requisition forms
Self-Check 5: Written Test
1. Explain at least three reasons for laboratory examination of urine.

2. Explain at least one reason for collecting specimens like sputum, blood or stool.
3. Mention purposes for sputum specimen collection.

4. Describe the process how to draw venous blood for laboratory investigation.
5. How can you obtain sterile urine specimen?
6. Differentiate between signs and symptoms.

Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
1. ________________________________________________________________
________________________________________________________________

________________________________________________________________
2. ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
3. ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
4. ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
5. ________________________________________________________________
________________________________________________________________
________________________________________________________________
6. ________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Information Sheet 6 Medication administration

6.1 Introduction
Pharmacology is the study of drugs. Drugs are chemicals that alter functions of living organism.
Therapeutic agents are drugs or medications that, when introduced in to living organism, modify
the physiologic functions of that organism.
6.2 Drug Metabolism

Drug metabolism in the human body is accomplished in four basic stages: absorption,
transportation, biotransformation, and excretion. For a drug to be completely metabolized, it
must first be given in sufficient concentration to produce desired effect on body tissues. When
this “Critical drug concentration” level is achieved, body tissue change.
6.3 Route of Absorption
Drugs are absorbed by the mucus membranes, the gastro intestinal tract, the respiratory tract, and
the skin. The mucus membranes are one of the most rapid and effective routes of absorption
because they are highly vascular.
Oral drugs (drugs that are given by mouth) are absorbed in the gastro intestinal tract. The rate of
absorption depends on the pH of the stomach‟s contents, the food contents in the stomach at the
time of ingestion, and the presence of disease conditions. Most of the drug concentrate dissolves
in the small intestine where the large vascular surface and moderate pH level enhance the
process of breaking down the drug.
Parental methods are the most direct, reliable, and rapid route of absorption. This method of
administration includes intradermal, subcutaneous, intramuscular (IM) and intravenous (IV). The
actual site of administration depends on the type of drug, its action, and the client. Another route
of medication include respiratory tract by inhalation, sublingual, buccal and topical.
6.4 Transportation
The second stage of metabolism refers to the way in which a drug is transported from the site of
introduction to the site of action. When the body absorbs a drug, a portion of the drug binds to
plasma protein and may compete with other drugs for this storage site.
Another portion is transported in “free” form through the circulation to all parts of the body. It is
the “free” drug that is pharmacologically active. As the free drug moves from the circulatory
system, it crosses cell membranes to reach its site of action. As the drug is metabolized and
excreted, protein bound drug is freed for action.
Lipid-soluble drugs are distributed to and stored in fat and then released slowly in to the
bloodstream when drug administration is discontinued. The amount of the drug that is distributed
to body tissues depends on the permeability of the membranes and blood supply to the
absorption area.

6.5 Biotransformation:- The third stage of metabolism takes place as the drug, which is a
foreign substance in the body; is converted by enzymes into a less active and harmless agent that
can be easily excreted. Most of this conversion occurs in the liver, although some conversion
does take place in the lungs, kidney plasma and intestinal mucosa
6.6 Excretion:- The final stage in metabolism takes place when the drug is changed in to an
inactive form or excreted from the body.
The kidneys are the most important route of excretion because they eliminate both the pure drug
and the metabolism of the parent drug.
During excretion, these two substances are filtered through glomeruli, secreted by the tubules,
and either reabsorbed through the tables or directly excreted. Other routes of excretion include
the lungs (which exhale gaseous drugs). Feces, saliva, tears, and mother‟s milk
6.7 Factors Affecting Drug metabolism
Many factors affect drug metabolism, including personal attributes, such as body weight, age,
and sex, physiologic factors, such as state of health or disease processes, acid-base and fluid and
electrolyte balance; permeability; diurnal rhythm; and circulatory capability.
Genetic and immunologic factors play a role in drug metabolism, as do psychologic, emotional
and environmental influences, drug tolerance, and cumulation of drugs. Responses to drugs vary,
depending on the speed with which the drug is absorbed into the blood or tissues and the
effectiveness of the body‟s circulatory system.
6.8 Source and Naming of Drugs
The primary natural sources from which drugs are compounded are roots, bark, sap, leaves,
flowers, and seeds of plants, other natural sources include animal organs or organ cells
secretions, and mineral sources. Synthetic drugs, such as sulfonamide, are made in a laboratory
from chemical substances.
Most drugs are given chemical, generic, and trademark names. The generic name is shorter and
simples and reflects the chemical fancily to which the drug belongs. The trade name is the most
common way in which the drugs are known. Once a drug is registered with a brand name, only
its legal owners can manufacture the drug.
6.9 Drug Administration

The route of drug administration influences the action of that drug on the body. To obtain a
systemic effect, a drug must be absorbed and transported to the cells or tissues that respond to
them. How a drug is administered depends on the chemical nature and quantity of the drug, as
well as on the desired speed of effect and the overall condition of the client.
Individual drugs are designed to be administered by specific route be sure to check drug labels
for the appropriate route of administration. Common routes of administration to obtain systemic
effects include the following: oral, sublingual, rectal, trans dermal, and parentral. Parentral
ingections are commonly administered in these sites: intradermal, subcutaneous, IM and IV.
6.10 Safety Procedures
When you administer drugs, you must follow certain safety roles, which are also known as “the
Five Rights.”
These rules should be carried out each time you give a drug to a client.
The Five Rights
- Right medication. Compare drug card, medication sheet or drug kardex (client‟s medication
record) three times, with label on drug container. Know action, dosage and method of
administration. Know side effects of the drug.
- Right client, check the client‟s identification-Name, Age, Bed number, and ward/door number.
- Right time
- Right method/route of administration
- Right amount/dosage- cheek all calculations of divided dose with another nurse.
6.11 Application of Nursing Process

- Assessment /Data base
- Assess route for drug administration
- Assess specific drug action for cheat
- Observe for sign and symptoms of side effects or adverse reactions
- Assess need for and accuracy of drug calculation
6.12 Planning /setting objectives

- To administer medications using correct route
- To determine appropriate drug actions
- To identify when side effects or adverse reactions occur
- To accurately calculate drug dosages.
6.13 Implementation /Intervention
- Preparing for drug administration
- Creating a rapport with the patient
- Assembling necessary equipment
- Converting medication
- Calculating dosage as appropriate
- Following the five rights
- Using the unit Dose system
- Using the Narcotic control system
6.14 Evaluation /Epected out comes
- Medications are administered by correct route
- Medication action and side effects are identified
- Drug dosages are calculated accurately
6.15 Different Routes of Drug Administration
 Oral
 Topical
 Parentral
 Intradermal
 Subcutaneous
 Intramuscularly
 Intravenous
 Rectal
 Vaginal
 Inhalation
I. Oral Administration

Definition: Oral medication is drug administered by mouth
Purpose
a. When local effects on GI tract are desired
b. When prolonged systemic action is desired
Contra- indications
1. For a patient with nausea & vomiting, unconscious patients.
2. When digestive juices inactivate the effect of the drug.
3. When there is inadequate absorption of the drug, which leads to inaccurate
determination of the drug absorbed.
4. When the drug is irritating to the mucus membrane of the alimentary canal.
Type of Oral Medication
1. Lozenges (troches) - sweet medicinal tablet containing sugar that dissolve in the mouth
so that the medication is applied to the mouth and throat
2. Tablets - a small disc or flat round piece of dry drug containing one or more drugs
made by compressing a powdered form of drug(s)
3. Capsules - small hollow digestible case usually made of gelatin, filled with a drug to be
swallowed by the patient.
4. Syrups - sugar containing medicine dissolved in water
5. Tinctures - medicinal substances dissolved in water
6. Suspensions - liquid medication with undissolved solid particles in it.
7. Pills and gargle - a small ball of variable size, shape and color some times coated with
sugar that contains one or more medicinal substances in solid form taken in mouth.
8. Effervescence - drugs given of small bubbles of gas.
9. Gargle - mildly antiseptic solution used to clean the mouth or throat.
10. Powder - a medicinal preparation consisting of a mixture of two or more drugs in the
form of fine particles.
Equipment
• Tray
• Towel

Note
1. Remember the 5 R's
 Right patient
 Right medication
 Right route
 Right dose
 Right time
2. Always keep the bottle tightly closed.
3. Clean and keep the label of the bottle clear.
4. Keep medication away from light.
5. Cheek their expiration date.
6. Keep the rim of the bottle clean.
7. Give your undivided attention to your work while preparing and giving medications.
8. Make sure that a graduate nurse checks some potent drugs.
9. Never give medications from unlabeled container
10. Never return a dose once poured from the bottle.
11. Check your patient's vital sign may be necessary before and after administrating some drugs
e.g. digitals, ergometrine.
12. Never give medicine that some one poured or drawn.
13. Never leave medicine at bed side of a patient and within reach of the children
II. Suppository
Purpose
• To produce a laxative effect. (bowel movement),suppository is used frequently instead of
enema since it is inexpensive.
• To produce local sedative in the treatment of hemorrhoids or rectal abscess.
• To produce general sedative effects when medications cannot be taken by mouth
• To check rectal bleeding
Equipment
• Suppository (as ordered)

• Gauze square
• Rectal glove or finger cot
• Toilet paper
• Receiver for soiled swabs
• Bedpan, if the treatment is in order to produce defection.
• Screen
• Mackintosh and towel
Kinds of Suppositories Used:
1. Bisacodyl (Dulcolax) is commonly ordered for its laxative action. It stimulates the
rectum and lubricates its contents.
Normally 15 minutes is needed to produce bowel movement.
2. Glycerin or suppository for bringing about bowel movement. If soap suppository is
used cut a splinter of soap 2-6 cm. loch and wash it in hot water to smooth the rough edges
before administration.
3. Bismuth - for checking diarrhea.
4. Opium, sodium barbital etc. for sedation
III. Parentral Drug Administration
A. Intradermal Injection
Definition: It is an injection given into the dermal layer of the skin
(corneum)
Purpose
For diagnostic purpose
a. Fine test (mantoux test)
b. Allergic reaction
For therapeutic purpose
c. Intradermal injection may also be given like in vaccination
Site of Injection
• The inner part of the forearm (midway between the wrist and elbow.
• Upper arm, at deltoid area for BCG vaccination

Equipment
• Tray
• Syringe & needle (sterile)
• Receiver
• Drug (to be injected)
• File
• Alcohol swab
• Marking pen
• Water in the bowel to rinse syringe and needle
B. Sub - Cutaneous Injection
Definition: Injecting of drug under the skin in the subcutaneous tissue, (under the dermis)
Purpose:
• To obtain quicker absorption than oral administration
• When it is impossible to give medication orally
Equipment
• Tray
• Sterile syringe & needle (disposable)
• Alcohol swabs
• Medication
• File
• Medication card and patient chart
• Receiver
• Water in a bowel
• Disposing box
Site of Injection
• Outer part of the upper arm
• The abdomen below the costal margin to the iliac crest.
• The anterior aspect of the thigh

Note: If repeated injections are given, the nurse should rotate the site of injection so that each
succeeding injection is about 5 cm away from the previous one.
C. Intera- Muscular Injection
Definition: It is an introduction of a drug into a body's system via the muscles.
Purpose
• To obtain quick action next to the intravenous route
• To avoid an irritation from the drug if given through other route.
Equipment
• Tray
• Ordered drug (ampoule, vial)
• Sterile syringes and needle in a container
• Alcohol swab
• Receiver
• A bowl of water for used syringes and needle
• File
• Sterile jar with sterile forceps
• Chart
Sites for I.M. Injection

• Ventrogluteal muscle

A=
Dorsogluteal muscle
• Deltoid muscle
• Vastus Lateralis

Note:
1. The needle for i.m. Injection should be long
2. Strict aseptic technique should be observed throughout the procedure.
3. Injection should not be given in areas such as inflamed, edematous, those containing
moles and pus.
D. I.V. INJECTIONS
 Definition: It is the introduction of a drug in solution form into a vein. Often the amount
is not more than 10.ml. at a time.
Sites for IV injection
1. Dorsal Venous network
2. Dorsal metacarpal Veins
3. Cephalic Veins
4. Radial vein
5. Ulnar vein
6. Baslic vein

7. Median cubital vein
8. Greater saphenous vein
Purpose
• When the given drug is irritating to the body tissue if given through other routes.
• When quick action is desired.
• When it is particularly desirable to eliminate the variability of absorption.
• When blood drawing is needed (exsanguinations)
Equipment
• Tray
• Towel and rubber sheet
• Sterile needle and syringes in a sterile container
• Sterile forceps in a sterile container
• Alcohol swabs
• File
• Medication
• Tourniquet
• Receivers (2)
• Treatment Chart
• Glove
Note:
1. Have a bowl of water to rinse the needle used immediate
2. Make yourself as well as the pt. Comfortable before giving injection.
3. It is the fastest way of drug administration
4. Never recup a used needle
E. Intravenous Therapy
 Definition: It is the administration of a large amount of fluid into the system through a
vein.
Purpose

• To maintain fluid & electrolyte balance
• To introduce medication particularly antibiotics.
Equipment
• IV fluid as ordered
• Sterile syringe & needle
• Rubber & towel
• Receiver
• Alcohol swabs
• Arm board
• Bandage & scissors
• Tourniquet
• I.V pole
• Adhesive tape
• Medication chart
Preparation of the Patient
 Since an infusion therapy takes several hours to complete, the patient should first be
made comfortable.
 Number of ml. of sol's number of drops in a ml.
 Number of hrs. over which sol. is to be administered x 60 minutes
 1ml = 15 drops
E.g. if 1000ml of 5% D/w is to run for 24 hrs, how many drops per minutes should it run?
1000 ml. x 15 gtt/ml. = 1000 x 15 gtt. = 10 gtt/min
24 x 60 min. 24 x 60 min.
Note:
1. The arm board should be long enough to extend beyond the wrist and elbow joint.
2. Board should be padded
3. Infusion bottle should be labeled with the date, time infusion is started, drops per
minute, and any added medications. If more than one bottle as used in 24 hrs, it should be
labeled as bag 1, 2,3, and so on.

4. Extend the arm in the most comfortable position.
5. Usual areas used for intravenous infusion are:
a) The median basilic vein on the inner surface of the arm.
b) A vein on top of the foot
c) In an infant the jugular vein and the scalp vein
F. Blood Transfusion
Definition: It is the giving of blood to a patient through a vein
Purpose
• To counteract severe hemorrhage and replace the blood loss.
• To prevent circulatory failure in operation where blood loss is considerable, such as in
rectal resection hysterectomy and arterial surgery.
• In severe burns to make up for blood lost by burning but only after plasma and
electrolytes have been replaced.
• For treatment of severe anemia due to cancer, marrow aplasia and similar conditions.
• To provide clotting factors normally present in blood, which may be absent as a result of
disease.
Equipment
• Bottle containing blood, with the patient name, blood group and Rh. Factor and expiry
date.
• Blood giving set
• Sterile syringes and needle
• Alcohol swabs
• Sterile gauze
• Rubber sheet and towel
• Tourniquet
• Arm splint
• Bandages and scissors
• Adhesive tape
• Receiver for dirty swabs

• I.V pole (stand)
• Patient's chart.
Note:
1. Always member to have anti- histamine injection ready in case a patient has reaction
from the blood.
2. Be familiar with the most usual symptoms of blood reactions which are:-
Immediate Reaction:
a) Headache
b) Backache
c) Chills
d) Pyrexia
e) Rash of the skin (urticaria )
Late Reaction
a) Dyspnea
b) Renal shut down in severe cases
c) Heamaturia
d) Chest pain
e) Rigor (rigidity)
Nursing Interventions in Transfusion Reaction
 Reactions following blood transfusion may occur for various reasons. Patient must be
informed that the supply of blood is not completely risk-free but that it has been tested
carefully. Nursing management is directed toward preventing complications and
promptly initiating measures to control any complications that occur.
 The following steps are taken so that a diagnosis may be made regarding the type and
severity of the reaction:
 The transfusion set is disconnected, but the intravenous line is kept patent with a normal
saline solution (0.9%) in case intravenous medication should be needed rapidly.
 The blood container and tubing are saved, not discarded.
They are sent to blood bank for repeat typing and culture.

The identifying tags and numbers are verified.
 The symptoms are treated as prescribed and vital signs are monitored.
 The patient blood is drawn from plasma hemoglobin, culture, and retyping.
 A urine sample is collected as soon as possible and sent to laboratory for a hemoglobin
determination. Subsequent voiding of urine should be observed.
 The blood bank is notified that a suspected transfusion reaction has occurred.
 The reaction is documented according to the institution‟s policy.
G. Cut Down
Definition - Dissection of a vein for inserting I.V cannula or needle.
Purpose
 When vein puncture is difficult
 When pro longed, continuos infusion is needed
 When rapid infusion is important and emergency situation combine these indications.
Equipment
Sterile
• Dressing forceps (1)
• Cotton balls in a gallpot
• Solution for cleansing
• Gloves
• Hole sheet (Fenestrated towel)
• Syringe and needle
• Scalpel (surgical knife)
• Mosquito forceps (3)
• Aneurysm needle (1)
• Silk
• Intravenous cannula or vein flow (2)
• Small, straight scissors (1)
• Small, curved scissors (1)
• Needle holder (1)

• Round needle (1)
• Cutting needle (2)
• Tissue forceps (1)
• Gauze (slit at one end)
• Probe
• Fine dissecting forceps (1)
• Local anesthesia
Clean
• Receiver of dirty swab
• Stand light, if available
• Adhesive tape (plaster)
• Dressing scissors
Administering Vaginal Medications
Purpose
• To treat or prevent infection
• To remove an offensive or irritating discharge
• To reduce inflammation
• To relieve vaginal discomfort
Equipment
• Prescribed vaginal suppository
• Client‟s applicator (should be kept in client‟s room)
• Clean gloves
Administering Ophthalmic Medications
Purposes:
• Instillation
- To provide an eye medication the client requires
• Irrigation
- To clear the eye of noxious or other foreign material or excessive secretion in the preparation
for surgery

Administering Ear Medications
Purpose:
 To relieve pain
 To treat infection
 To better visualize during examination
Equipment
• Disposable tissues
• Medication
• Cotton ball
• Gloves
H. Inhalation
• Definition: Inhalation is the act of drawing in of gas vapor or steam into the lungs for
therapeutic purposes it could be in dry, moist or vapour form.
i. Oxygen Administration:
Purpose
• To provide and maintain a normal supply of o2 for blood, and tissues. o2 may be
administered in three ways.
1. By mask
2. Nasal Catheter
3. Tent.
1. Giving O2 by mask
There are many kinds of masks used for O2 administration the common ones are:
1. The venture mask
2. The B.L.B. masks (Boothby. Lovelace & Bulbulain)
The venture mask gives a controlled amount of O2 i.e. it is not high to cause respiratory
depression & it is sufficient to relieve anoxia. It gives 24-35% of O2
The B.L.B mask provides an oxygen concentration of 90% with the flow meter set at 7
liters/minute. This kind of mask allows the patient to eat, drink and to expectorate. If the patient
cannot breath through his nose, the B.L.B mask should not be used.

Equipment
• A cylinder of O2 with a reducing value and pressure tubing to be connected with the O2
cylinder.
• Mask
• Safety pin to secure the tubing to the bed linen
• Tissue paper to clean the nostrils with. If the patient is unconscious, a tray containing a
galipot of saline or water, wooden applicator and receiver for soiled applicator is necessary
in order to clean the nostrils
2. Giving oxygen by nasal catheter.
There are different kinds of catheters,
a) A fine catheter
b) A spectacle frame, which carries two, places of rubber tubing and is worn by the pt.
c) Two soft rubber catheters connected by y- shaped connection to the tube on O2
apparatus.
Equipment
 Oxygen cylinder with regulating valve and pressure tubing
 Wolf‟s bottle
 Glass connection
 Fine catheters, lubricant, plaster
 Safety pin
 Tray containing a galipot of saline or water. Receiver for soiled applicators.
Note:
• Oxygen catheter are removed every 8 hrs. and a clean catheter is inserted into the other
nostril. Patient's receiving oxygen by catheter requires special mouth and nose care since
the catheter tends to irritate the mucous membrane. Oxygen dries and irritates mucous
membrane, therefore, should be passed through water (Humidified) before it is
administered by catheter. The advantage of administration of oxygen by catheter is the

freedom of movement that it gives to patients receiving oxygen. By this method patient
can obtain about 50% concentration of oxygen.
3. Oxygen tent
Purpose:
a) To keep patient in high oxygenation environment.
b) Whenever the other means are not possible.
Equipment
1. Transparent oxygen tent and its apparatus fitted with oxygen
2. Ice if the apparatus is with out refrigerator device.
3. Hanger for the tent
4. Room thermometer if needed
5. No smoking sign for the unit
Precautions to be taken when Oxygen is used
1. Oxygen supports combustion. Therefore it is essential for the patient's safety their is no
smoking within 3 meters of oxygen equipment. Lighted matches, cigarettes, electric lights, nylon
clothing, electric pads, bells mechanical toys should be forbidden.
2. Alcohol must not be applied to the pt's skin
3 The catheter tip and the cylinder itself must not be lubricated with Vaseline or oil or
any kind
4. Cylinders must be handled carefully as the oxygen is under pressure.
5. The fine adjustment should always be closed when the main tap is turned on.
6. Check that there is no obstacle in the pt's airway before firing oxygen in order to
prevent pt. from suffocation.
7. A rate of 2-liters/ minute is commonly used when oxygen used in case of emergency
instead of free air. In the case of asphyxia liter/min may be needed. Protect patient from
asphyxia, inspecting regularly pressure gauge and flow meter and noting pulse, respiration, color,
mental state and necrosis from carbon dioxide.
ii. Steam Inhalation
Definition: It is the intake of steam alone or with medication through the nose or mouth

Purpose
1. In order to produce a local effect on the upper respiratory passage during cold,
sinusitis, laryngitis, bronchitis etc. common drugs used are frier balsam (tincture of benzoin
compound, eucalyptus. Menthol, camphor)
2. To allay spasm e.g. Asthma, angina pectoris
3. To increase circulation in the lungs by increasing or decreasing the secretion of the
bronchi.
E.g. ammonia inhaled in cases of fainting and syncope stimulated the respiratory center and heart
action.
4. To moisten secretions e.g. Tracheotomy
There are two Types of Inhalation
1. Intermittent (interrupted) e.g. Nelson's inhaler.
2. Continues method e.g. steam tent.
1. Nelson's Inhaler
Equipment
• Nelson's inhaler with the mouth piece
• Cover for the inhaler (blanket or towel)
• A bowl or saucepan to carry the inhaler
• Face towel to wipe the face as patient required
• Gauze can be use around the mouthpiece to prevent burning of the lips.
• A tray should be large enough, to carry the inhaler to take it to the bedsides.
• A measuring jug with water which is 820C
• The drug ordered might be eucalyptus, tincture of benzene (about 4 cc).
N.B:
1. If a Nelson's inhaler is not available a wide- mouthed jug may used. The patient should
be covered up to the waist with a balance from a canopy, or the mouth of the jug may be covered
with a towel to make the opening small enough for the patient to put his nose and mouth (not
eyes) on it.
2. For irrational, helpless patients, stay with them throughout the procedure.
3. Report the amount and nature of any sputum or discharge.
Care of Equipment after use

• Pour out the water from the inhaler (not onto a sink)
• Wash the inhaler with hot water
• Boil the mouth piece
Emergency tray and Trolley : List of Emergency Drugs.
• O2 - Tourniquet
• Morphine sulfate - O2 mask or nasal catheter
• Aramine - plaster
• Adrenalin( Epinephrin.) - Dressing scissors
• Levophed -Arm Board
• Phenergan - Small makintosh '' towel''
• Aminophylline - Tongue depressor
• Allercur - Mouth gag
• Nor adrenaline - Air way
• Carmine (Nikethamide) - suction machine
• Lasix - Files
• Syringes and needles - Container with alcohol
• Digoxin - Receiver
• Na HCO3 (Sodium bicarbonate) - Bandage
• Swabs - Levin's tube
• Vitamin k - Ned blacks
• 0 .9% Normal Saline
• 5% D/w with complete set
• Largactil
• Diazepam
• Ergometrine
• Kcl (potassium chloride)
• 40% dextrose
1. Which one of the following rout of drug administration has fastest action? (2 Point)
a. Oral c. Intravenous
b. Subcutaneous d. Rectal
2. Mention two indications for oral drug administration (3 point)
3. State the 5 Rs during drug administration.(5 Point)
4. Which one of the following site of injection most preferred for young children? (2 point)

a. Vastus lateralis c. Deltoid muscle
b. Ventrogluteal d. Dorsogluteal
5. Explain the difference between intravenous injection and intravenous infusion.(3 point)
6. List at least three immediate complications of blood transfusion.(3 point)
7. Define inhalation (2 point)

Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
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3. ________________________________________________________________
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4________________________________________________________________
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5. ________________________________________________________________
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Operation Sheet 9 Oral medication
Step 1: Prepare your tray and take it to the patient's room

Step 2: Begin by checking the order
Step 3: Read the label 3 times
Step 4: Place solution and tablets in a separate container.
Step 5: If suspension, shake the bottle well before pouring
Step 6: Take it to the pt's bedside
Step 7 Keep the medication in site at all time

Step 8: Identify the patient carefully using all identification variables.(Pt‟s name, bed number…)
Step 9: Remain with the pt. until each medicine is swallowed
Step 10: Offer additional fluid as necessary unless contra-indicated
Step 11: Record the medication given, refused or omitted immediately.
Step 12: Take care of the equipment & return them to their proper places.
Step 13: Wash your hands.
Operation Sheet 10 Suppository medication
Step 1. Check medication order.

Step 2. Review client‟s medical record for rectal surgery/ bleeding.
Step 3. Wash hands.
Step 4. Prepare needed equipment and supplies.
Step 5. Apply disposable gloves
Step 6. Identify client.
Step 7. Explain procedure to client.
Step 8. Arrange supplies at client‟s bedside.
Step 9. Provide privacy.
Step 10. Position client in Sims‟ position.
Step 11. Keep client draped, except for anal area.
Step 12. Examine external condition of client‟s anus. Palpate rectal walls.
Step 13. Dispose of gloves, if soiled, and reapply new gloves.
Step 14. Remove suppository from wrapper and lubricate rounded end.
Step 15. Lubricate gloved finger of dominant hand.
Step 16. Ask client to take slow, deep breaths through mouth and to relax anal sphincter.
Step 17. Retract client‟s buttocks with nondominant hand.
Step 18. With index finger of dominant hand, gently insert suppository through anus, past the
internal sphincter, and place against rectal wall, 10 cm for adults or 5 cm for children and infants.
Step 19. Withdraw finger and wipe client‟s anal area clean.
Step 20. Remove and dispose of gloves.

Step 21. Wash hands.
Step 22. If suppository contains a laxative or fecal softener, be sure that client will receive help
to reach bedpan or toilet.
Step 23. Keep client flat on back or on side for 5 minutes.
Step 24. Return in 5 minutes to determine if suppository has been expelled.
Step 25. Observe client for effects of suppository 30 minutes after administration.
Step 26. Record medication administration.
Operation Sheet 11 Intradermal Injection
Step 1: Take equipment to the patient's side

Step 2: Explain procedure to patient
Step 3: Get hold of the arm & locate the site of injection.
Step 4: Clean the skin with swab and inject the drug about 0.1. 0.2 inch in to the epidermis after
the bevel of the needle is no longer visible. Don't massage the site.
Step 5: Check for the immediate reaction of the skin (10-15 minutes later for tetanus, 20-30
minutes later for penicillin)
Step 6: If it is for tine test, mark the area
Step 7: Chart the data and time of the administration of the drug.
Step 8: Take care of the equipment & return to their places.
Step 9: Do not forget to do the reading after 72 hours if it is for fine test (tuberculin test)
Step 10: Document about the procedure
Operation Sheet 12 Sub - Cutaneous Injection
Step 1: Take equipment to the pt's bed side or room

Step 3: Draw your medication
Step 4: Expel the air from the syringe
Step 5: Clean the site (usually it is in upper arms, thighs or abdomen)
Step 6: Grasp the area between your thumb & forefinger to tense it.

Step 7: Insert the needle elevate about 450 - 600 angle.
Step 8: Pierce the skin quickly & advance the needle
Step 9: Aspirate to determine that the needle has not entered a blood vessel
Step 10: Inject the drug slowly.
Step 11: After injecting withdraw the needle and massage the area with alcohol swab.
Step 12: Chart the amount and time of administration immediately.
Step 13: Take care of the equipment- wash, sterilize and return to its place
Step 14: Watch for undesired reaction (side effect of the drug) etc.
Operation Sheet 13 Intera- Muscular Injection
Step 1: Do the ABC of the procedure.

Step 2: Prepare tray & take it to the patien‟s room
Step 3: Prepare the medication
Step 4: Draw the medicine
Step 5: Expel the air from the syringe
Step 6: Choose the site of injection (the site for intramuscular)
Step 7: Using the iliac crest as the upper boundary divided the buttock into four. Clean the upper
outer quadrant with alcohol swab:
Step 8: Stretch the skin and inject the medicine
Step 9: Draw back the piston (plunger) to check whether or not you are in the blood vessel ( if
blood returns, withdraw and get a new needle & reinject in a different spot)
Step 10: Push the drug slowly into the muscle
Step 11: When completed, withdraw the needle and massage the area with swab gently to and
absorption.
Step 12: Place the patient comfortably
Step 13: Take care of the equipment you have used & return to their places
Step 14: Chart the amount, time route and type of the medicine
Step 15: Check the patient's reaction

Operation Sheet 14 IV injection
Step 1: Prepare your tray & the medication

Step 3: Position the patient properly
Step 4: Place rubber and towel under his arm(to protect the bed linen)
Step 5: Expose the arm and apply tourniquet
Step 6: Ask pt to open and close his fist.
Step 7: Palpate the vein and clean with alcohol swab the site of the injection (Which is mainly
the mid cubital vein of the arm)
Step 8: Clean with a circular motion; proceed from center of the site outward.
Step 9: Hold the needle at about 450 angles in line with the veins.
Step 10: Puncture the vein and draw back to check whether you are in the vein or not. (Blood
return should be seen if you are in the vein)
Step 11: Once you know that you are in the vein, release the tourniquet and gently lower the
angle of the needle
Step 12: When it is nearly paralleled to the vein and instills the medications. Give very slowly
unless there is an order to give it fast (Normally 40-60 drops is given in 1 minute).
Step 13: Check the pt's pulse in between. Any complaint from the patient should not be ignored.
Step 14: Apply pressure over the site after removing the needle to prevent bleeding. Tell patient
to flex his elbow.
Step 15: Watch the patient for few minutes before leaving him.
Step 16: Remove your equipment
Step 17: Put the pt. In a comfortable position
Step 18: Wash, sterilize and place the equipment in order.
Step 19: Chart the medication given the amount, time & the reaction of the pt.
Operation Sheet 15 Intravenous Therapy

Step 1: Take equipment to the patient's bedside
Step 2: Explain the procedure to the patient. Be sure you have right patient.
Step3: Remove air form the tubing
Step 4: Place rubber & towel under the arm
Step 5: Apply tourniquet about 3 c.m. above the intended site of entry.
Step 6: Observe & palpate for suitable vein
Step 7: Cleanse the skin with alcohol swabs thoroughly & place the swab used thumb the retract
down the vein & soft tissue 4 c.m. below the intended site of injection.
Step 8: Hold needle at 450 angle line with the vein
Step 9: Pierce the skin and puncture the vein
Step 10: Check if you are in the vein by drawing back with the syringes. (blood returns if you are
in the vein)
Step 11: Release the tourniquet gently
Step 12: Start the flow of solution by opening the clamp.
Step 13: Support needle with sterile gauze or sterile cotton balls If necessary to keep it in proper
position in the vein
Step 14: Anchor the I.V. tubing with the adhesive tape to prevent pull on the needle.
Step 15: Place arm board or splint under the arm and bandage around.
Step 16: Adjust the rate of flow
Step 17: Rate of flow is regulated by the following formula.
Operation Sheet 16 Blood Transfusion
Step 1: Explain procedure to patient

Step 2: Before blood transfusion is administered, the nurse has to
Step 3: check the blood group & RH- factor if cross match of thevdonor's & the recipient‟s blood
is done and is compatible. And also check for HIV other blood born pathoges.
Step 4: Prepare the tray with necessary items
Step 5: Before taking it to the patient's room, check the patient's name, hospital number, bed
number, blood group, Rh. Factor and the expiry date with a 2nd nurse or a doctor.

Step 6: Blood should be used within 21 days of its withdrawal date, if sodium citrate is used it
can be used until 36 days.
• Take it to the pt's room
• Hang the bottle & remove the air from the tubing
• Put pt. in a comfortable position.
• Place rubber & towel under the arm
• Check the vital signs before administering
• Choose the vein
• Apply tourniquet
• Clean the skin & feel for a distended vein & clean again.
• Puncture the vein with the needle (the needle here should be short and wide so that it
does not cause occlusion easily)
• After you make sure that you are in the vein release tourniquet & open the clamp.
The drop/minute at the beginning should be very slo
Step 7: Watch patient closely for any reaction
Step 8: If there is no reaction from the patient regulate the rate of flow according to the patient's
conditions & the order.
• Splint the arm & position it comfortably.
• Remove the equipment you have used, wash and return to its proper place.
• Record the time you started the blood & any other pertinent information.
• Check pt. frequently.
Operation Sheet 17 Cut Down
Step 1: Bring equipment to the bedside of the patient

Step 2: Explain procedure to the patient
Step 3: Shave the area, if needed
Step 4: Position the patient properly
Step 5: The nurse will then open the set and pour the cleaning lotion in to the galipot for the
doctor

Step 6: The doctor then scrub his hands, put on gloves, clean and drape the area, he will insert
the I.V
Step 7: The channel is securely tied with silk and skin is closed
Step 8: The nurse dresses the site and secure it with adhesive plaster
Step 9: Remove all equipment, wash and send for sterilization.
Operation Sheet 18 Administering Vaginal Medications
Step1. Check medication order.

Step. Wash hands.
Step 3. Prepare equipment and supplies.
Step 4. Identify client.
Step 5. Inspect client‟s external genitalia and vaginal canal.
Step 6. Assess client‟s ability to manipulate applicator and position herself.
Step 9. Provide privacy.
Step 10. Assist client to dorsal recumbent position.
Step 11. Keep client‟s abdomen and lower extremities draped.
Step 12. Apply disposable gloves.
Step 13. Provide adequate lighting.
Step 14. Insert suppository:
A. Take suppository from wrapper and lubricate smooth or rounded end.
B. Lubricate gloved finger of dominant hand.
Offer client perineal pad.
Step 15. Apply cream or foam:
A. Fill applicator as directed.
B. Retract client‟s labial folds with nondomi-nant gloved hand.
C. With dominant gloved hand, insert applicator 5 to 7.5 cm; push plunger.

D. Withdraw applicator and place it on paper towel. Wipe away lubricant from client‟s
ori-fice and labia.
E. Wash applicator and store for future use.
Step 16. Remove and discard gloves.
Step 18. Instruct client to remain flat on her back for at least 10 minutes.
Step 20. Inspect condition of client‟s vaginal canal and external genitalia between applications.
Step 21. Record medication administration.
Step 22. Retract client‟s labial. folds with nondomi-nant gloved hand.
Step 23. Insert rounded end of suppository 7.5 to 10 cm along posterior wall of vaginal canal.
Step24, . Withdraw finger and wipe away lubricant from client‟s orifice and labia.
Operation Sheet 19 Administering Ophthalmic Medications
Step 1. Review prescriber‟s medication order.

Step 2. Assess condition of client‟s external eye structures.
Step 3. Determine whether client has any known allergies to eye medications. Ask if client is
allergic to latex.
Step 4. Determine whether client has any symptoms of visual alterations.
Step 5. Assess client‟s level of consciousness and ability to follow directions.
Step 6. Assess client‟s knowledge regarding drug therapy and desire to self-administer
medication.
Step 7. Assess client‟s ability to manipulate and hold eye dropper.
Step 9. Wash hands.

Step 11. Apply clean gloves.
Step 12. Ask client to lie supine or to sit back in chair with head slightly hyper extended.
Step 13. Wash away any crusts or drainage along client‟s eyelid margins or inner canthus. Soak
any crusts that are dried and difficult to remove by applying a damp washcloth or cotton ball
over eye for a few minutes.
Step 14. Hold cotton ball or clean tissue in nondominant hand on client‟s cheekbone just below
lower eyelid.
Step 15. With tissue or cotton ball resting below lower lid, gently press downward with thumb or
fore-finger against bony orbit.
Step 16. Ask client to look at ceiling.
Step 17. Instill eye drops while explaining steps to client:
A. With dominant had resting on client‟s forehead, hold filled medication eye dropper or
ophthalmic solution approximately 1 to 2 cm above conjunctival sac.
B. Drop prescribed number of medication drops into conjunctival sac.
C. If client blinks or closes eye or if drops land on out lid margins, repeat procedure.
D. For drugs that cause systemic effects, with a clean tissue apply gentle pressure
with your finger and clean tissue on the client‟s nasolacrimal duct for 30 to 60 seconds.
E. After instilling drops, ask client to close eye gently.
Step 18. Instill eye ointment
A. Ask client to look at ceiling.
B. Holding ointment applicator above lower lid margin, apply thin stream of ointment
evenly along inner edge of lower eyelid on conjunc-tiva from inner canthus to outer canthus.
C. Have client close eye and rub lid gently in circular motion with cotton ball, if rubbing
is not contraindicated.
Step 19. Intraocular disk procedures:
A. Application:
(1) Wash hands.
(2) Put on gloves.

(3) Open package containing disk. Gently press fingertip against disk so it adheres to finger.
Position convex side of disk on fingertip.
(4) With other hand, gently pull client‟s lower eyelid away from the eye. Ask client to look up.
(5) Place disk in the conjunctival sac so that it floats on the sclera between the iris and lower
eyelid.
(6) Pull client‟s lower eyelid out and over disk.
B. Removal:
(1) Wash hands.
(2) Put on gloves.
(3) Explain procedure to client.
(4) Gently pull on client‟s lower eyelid to expose disk.
(5) Using forefinger and thumb of opposite hand, pinch disk and lift it out of client‟s eye.
Step 20. If excess medication is on eyelid, gently wipe eyelid from inner to outer canthus.
Step 21. If client had an eye patch, apply clean patch by placing it over affected eye so entire eye
is covered. Tape securely without applying pressure to eye.
Step 22. Remove gloves.
Step 23. Dispose of soiled supplies in proper receptacle.
Step 25. Note client‟s response to instillation. Ask if any discomfort was felt.
Step 26. Observe client‟s response to medication by assessing visual changes and noting any side
effects.
Step 27. Ask client to discuss drug‟s purpose, action, side effect, and technique of
administration.
Step 28. Have client demonstrate self-administration of next dose.
Step 29. Record drug administration and appearance of client‟s eye.
Step 30. Record and report and undesirable side effects.
Operation Sheet 20 Administering Ear Medications
Step 1. Check the medication order against the original physician‟s order.

Step 2. Wash hands carefully.
Step 3. Prepare the medication following the “five rights.”
Step 4. Proceed to the client‟s bed side and identify the client.
Step 5. Put on gloves
Step 6. Ask the client to lie on the side of unaffected ear.
Step 7. Remove excess drainage with a dry wipe.
Step 8. Expose the external ear canal by properly adjusting the client‟s ear lobe. For adults, pull
the lobe up, back, and outward. For children, pull the lobe down and back.
Step 9. (a) Hold the dropper or the tip of the squeeze bottle above the opening of the external
auditory canal. Allow the prescribed number of drops to fall on the side of the canal.
(b) Do not touch any part of the ear with the dropper or squeeze bottle during
administration.
Step 10. Instruct the client to remain the side-lying position for 5-10 minutes with the affect ear
upward.
Step 11. If the procedure is ordered for both ears, allow 5-10 minutes between instillation. Report
the above steps for the other ear.
Step 12. Dispose of gloves and wash hands.
Step 13. Document the procedure.
Operation Sheet 21 Oxygen Administration:
Step 1. The adjustment is turned on before bringing the cylinder to the bedside.
Step 2. Explain treatment to pt.
Step 3. Bring equipment to the bedside
Step 4. Ask him to clean his nostril to avoid obstruction (if well enough)
Step 5. Connect the mask to tubing and open the fine adjustment to the required rate of flow.
Then apply the mask to the patient's face making sure that it rests comfortably on the pt's face.
See that the tubing is secured to the bed linen by means of safety pin. Stay with the patient till he
is reassured if it is his first time to be on oxygen therapy.

Operation Sheet 22 Giving oxygen by nasal catheter
Step 1. Procedure is the same as giving oxygen by mask: (Procedure 1-4)

Step 2. Connect the fine catheter with the pressure tubing. Turn on the fine adjustment to the
required rate of flow the maximum liter flow being 6-7 litter /minute.
Step 3. Catheter is lubricated preferably with water and passed backward into pharynx till the tip
of the catheter is opposite the uvula. The catheter can also be inserted by measuring the distance
from the patient's nose to his ear lobe. It is then taped in place. Never force catheter against an
obstruction.
Operation Sheet 23 Giving oxygen by Oxygen tent
Step 1. Remove all electrical appliances from the room as this may produce sparks.
Step 2. Post sign of no smoking on many places in the unit
Step 3. Prepare and check if the applicator is working properly.
Step 4. Bring the oxygen unit to the bedside and fix the tent on the hanger.
Step 5. Close all appliances of the tent: place ice if the apparatus is without refrigeration device.
Step 6. Tuck the side of the hold of tent under the mattress as far as they will go.
Step 7. Fill the tent with 12-15 liters of oxygen 40-60% concentration for the first half hour.
Step 8. After the first half hour regulate the flow of oxygen to 6-10 liters or as ordered by the
doctor until the treatment is completed.
Step 9. Check temperature indicator frequently and adjust to 180C- 220C.
Step 10. Record state of patient and time started and the flow of the oxygen.
Operation Sheet 24 Steam Inhalation

Step 1: Inhaler should be warmed and glass mouthpiece boiled
Step 2: Measure the drug as ordered. Either point in the graduate measure 90 cc of cold water
and 500 cc of boiled water to bring the temperate 820c or half by half or pour half point (300cc)
of boiling water into the inhaler than 5 cc of tincture of benzene or any other drug ordered.
Step 3: Then add 300 cc water making sure that the temperature of water in the inhaler comes to
820C. This is done in order to have a good mixture of the drug. The level of the fluid should not
be above the spout.
Step 4: Fix the mouthpiece firmly in the inhaler in direction opposite to the air inlet and cover the
inhaler with blanket or towel
Step 5: Close windows.
Step 6: Prepare the patient usually in a sitting - up position making sure that he/she is well
supported.
Step 7: Then put inhaler on a saucepan on the tray.
Step 8: Place the tray on the over- bed table or on his knees in such a way that he can bend over
the inhaler easily.
Step 9: Put the spout for the escape of steam away from him.
Step 10: Cover his head with blanket.
Step 11: Tell the patient to breath in by putting his lip to the mouth piece which may be protected
by a piece of gauze, and breath out by removing his lips for a moment from the mouth piece.
Step 12: The treatment can take from 5-10 minutes after which the patient should be kept warm
and comfortable for some time.

Name: _____________________________ Date: ________________

Instructions: Given necessary templates, tools and materials you are required to
perform the following tasks within 3 hours.
1. Administer oral medication

2. Provide Suppository medication
3. Administer Intradermal Injection
4. Provide subcutaneous injection
5. Administer Intera- Muscular Injection
6. Provide IV injection
7. Administer Intravenous Therapy
8. Provide blood transfusion
9. Perform G. Cut Down
10. Administering Vaginal Medications
11. Administering Ophthalmic Medications
12. Administering Ear Medications

13. Administer oxygen by nasal catheter
14. Administer oxygen by Oxygen tent
15. Provide Steam Inhalation
Information Sheet 7 Body mechanics and patient transport
1.1 Introduction: Body Mechanics: is the effort; coordinated, and safe use of the body to
produce motion and maintain balance during activity.
Proper Body Mechanics
Use of safest and most efficient methods of moving and lifting is called body mechanics. This
means applying mechanical principles of movements to the human body.
1.2 Basic Principles of Body Mechanics
1. It is easier to pull, push, or roll an object than to lift it. The movement should be
smooth and continuous, rather than jerky.
2. Often less energy or force is required to keep an object moving than it is to start and
stop it.
3. It takes less effort to lift an object if the nurse works as close to it as possible. Use the
strong leg and arm muscles as much as possible. Use back muscles, which are not as strong, as
little as possible. Avoid reaching.
4. The nurse rocks backward or forward on the feet and with his or her body as a force for
pulling or pushing. Principles under lying proper body mechanics involve three major factors:
center of gravity, base of support, and line of gravity.
1.3 Center of Gravity

The person‟s center of gravity located in the pelvic area. This means that approximately half the
body weight is distributed above this area, half below it, when thinking of the body divided
horizontally. In addition, half the body weight is to each side, when thinking the body divided
vertically. When lifting an object, bend at knees and hips, and keep the back straight. By doing
so, the center of gravity remains over the feet, giving extra stability. It is thus easier to maintain
balance.
1.4 Base of Support
A person‟s feet provide the base of support. The wider the base of support, the more stable the
object with in limits. The feet are spread side wise when lifting, to give side-to side stability. One
foot is placed slightly in front of the other for back-to-front stability. The weight is distributed
evenly between both feet. The knees are flexed slightly to absorb jolts. The feet are moved to
turn the object being moved.
1.5 Line of Gravity
Draw an imaginary vertical (up and down) line through the top of the head, the center of gravity,
and the base of support. This becomes the line of gravity, or the gravity plane. This is the
direction of gravitational pull (from the top of the head to the feet). For highest efficiency, this
line should be straight from the top of the head to the base of support, with equal weight on each
side. Therefore, if a person stands with the back straight and the head erect, the line of gravity
will be approximately through the center of the body, and proper body mechanics will be in
place.
1.6 Body Alignment
When lifting, walking, or per forming any activity, proper body alignment is essential to
maintain balance. When a person‟s body is in correct alignment, all the muscles work together
for the safest and most efficient movement, without muscle strain. Stretching the body as tall as
possible produces proper alignment. This can be accomplished through proper posture. When
standing, the weight is slightly forward and is supported on the out side part of the feet.
Again the head is erect, the back is straight, and the abdomen is in (remember that the client in
bed should be in approximately the same position as if he/she were standing).
1.7 Positioning the client

Encouraging clients to move in bed, get out of bed, or walk serves several positive purposes.
Prolonged immobility can cause a number of disorders, among which are pressure ulcer,
constipation, and muscle weakness, pneumonia and joint deformities. By assisting clients to
maintain or regain mobility, you promote self-care practices and help to prevent deformities.
1.8 Moving and Positioning Clients
Moving and positioning promote comfort, restore body function, prevent deformities, relieving
pressure, prevent muscle strain, and stimulate proper respiration and circulation.
1.9 Purpose:
 To increase muscle strength and social mobility
 To prevent some potential problems of immobility
 To stimulate circulation
 To increase the patient sense of independence and selfesteem
 To assist a patient who is unable to move by himself
 To prevent fatigue and injury
 To maintain good body alignment
1.10 Practice Guideline
• Maintain functional client body alignment. (Alignment is similar whether client is
standing or in bed.)
• Maintain client safety.
• Reassure the client to promote comfort and cooperation.
• Properly handle the client‟s body to prevent pain or injury.
• Follow proper body mechanics.
• Obtain assistance, if needed, to move heavy or immobile clients.
• Follow specific physician orders.
• Do not use special devices (e.g. splints, traction unless ordered)
Turning the Patient to a Side-lying Position
Supplies and Equipment
• Pillows
• Side rails

• Cotton blanket or towels, rolled for support
1.11 Joint Mobility and Range of Motion
Every body joint has a specific but limited opening and closing motion that is called its range of
motion (ROM). The limit of the joint‟s range is between the points of resistance at which the
joint will neither open nor close any further. Generally all people have a similar ROM for their
major joints.
1.12 Passive Range of Motion
If a client is unable to move, the nurse helps by performing passive range of motion (PROM)
exercise.
1.13 Controlling Postural Hypotension
 Sleep with the head of the bed elevated (8-12 inches).
This makes the person‟s position change on rising less severe.
 Avoid sudden changes of position. Arise from bed in three steps:
⇒ Sit on the side of the bed with legs dangling for 1 minute
⇒ Stand with core holding on to the edge or the bed or another non mobile object for 1 minute
⇒ Sit up in the bed for one minute
Gradual change in position stimulates renin, kidney enzyme that has a role in regulating BP and
which prevents a dramatic drop in BP
 Balance is maintained with minimal effort when the base of support is enlarged in the
direction in which the movement will occur
 Contracting muscles before moving an object lessens the energy required to move it
 The synchronized use of as many large muscles groups as possible during an activity
increases overall strength and prevents muscle fatigue and injury
 The closer the line of gravity to the center of the base of support, the greater the stability
 The greater the friction against the surface beneath an object the greater the force
required moving the object. (Pulling creates less friction than pushing)
 The heavier the object, the greater the force needed to move the object
 Moving an object along a level surface required less energy than moving an object up an
inclined surface or lifting it against gravity

 Continuous muscle exertion can result in muscle stretch and injury
1.14 Body Positioning
 Positioning client in various positions is done for diagnostic and
 therapeutic purposes. Some of the reasons include promoting
 comfort, restoring body function, preventing deformities, relieving
 pressure, preventing muscle strain, restoring proper respiration and
 circulation and giving nursing treatment
1.15 Guideline for Positioning the Client

Positioning the Client for Comfort
 Maintain functional client body alignment. (Alignment is Similar whether the client is
standing or in bed.)
 Maintain client safety.
 Reassure the client to promote comfort and cooperation.
 Properly handle the client‟s body to prevent pain or injury.
 Follow proper body mechanics.
 Obtain assistance, if needed to move heavy or immobile clients.
 Follow specific orders.
 Do not use special devices (e.g. Splints, traction) unless ordered client positioning for
examination and treatment.

1.16 Crutch Walking
Crutches: - are walking aids made of wood or metal in the form of a shaft. They reach
from the ground to the client‟s axillae.
Application of Nursing Process
Assessment
- Assess physical ability to use crutches and strength of the client‟s arm back, and leg muscle.
- Observe client‟s ability to balance self.
- Note any unilateral or unusual weakness or dizziness.
- Assess which gait is appropriate for client.
- Assess client‟s understanding of crutch-waking technique.
1.17 Planning/Objective

- To improve client‟s ability to ambulate when he/she has lower extremity injury.
- To increase muscle strength, especially in arms and legs.
- To increase feeling of well-being when client can ambulate.
- To promote joint mobility
1.18 Implementation/Procedure
- Teaching muscle- strengthening exercises
- Measuring client for crutches
- Teaching crutch walking: Four-point gait, Three-point gait, two-point gait.
- Teaching Swing-To-Gait and Swing-Through Gait
- Teaching upstairs and downstairs ambulation with crutches.
1.19 Evaluation/Expected Outcomes

- Client‟s ability to ambulate is improved.
- Muscle strength of client‟s arms and legs is improved
- Client experiences a feeling of well-being
1.20 Teaching Techniques of Crutch Walking
A. Four-Point Gait
Equipment
- Properly fitted crutches
- Regular, hard soled street shoes
- Safety belt, if needed

1. State the principle underlying proper body mechanics and relate a nursing consideration.
(3 point)
2. State the purposes of range of motion exercise. (3 point)
3. Identify principles related to safe movement of clients in and out of bed. (3 point)
4. Demonstrate the ability to move a partially mobile client safely from bed to chair and
back. (4 point)
5. Demonstrate the ability to teach each of the crutch walking gaits to a client. (4 point)
6. Mention different positions used for various examination and treatment. (3 point)

Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
1. ________________________________________________________________
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3.________________________________________________________________
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4. ________________________________________________________________
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Information Sheet 8 Cold Compress
1.1 Cold Application

Purpose
• To relieve pain: cold decrease prostaglandin's, which intensify the sensitivity of pain receptors
and other substances at the site of injury by inhibiting the inflammatory processes
• To reduce swelling and inflammation: by decreasing the blood flow to the area
(vasoconstriction effect)
• Reduce raised body temperature due to fever Cold can be applied in moist (cold compress 18-
27 c) and dry form (ice pack (bag) <15 oc)
Systemic effects of cold – extensive cold application can increase blood pressure
Systemic effects of Hot – produce a drop in blood pressure – excessive peripheral vasodilatation
1.2 Tepid Sponging
Definition: sponging of the skin with alcohol or cool water.
Purpose: to lower body temperature (fever)
Tepid (Lukewarm) water + alcohol
3 parts water: 1 part alcohol
The temperature of the water is 32 c (below body temperature) 27- 37 – alcohol evaporates at a
low temperature and therefore removes body heat rapidly
• Less frequently used – because alcohol causes skin drying

• Heat loss is by conduction and vaporization
• Determine the patients‟ temperature, PR and RR frequently every (Q) 15 min
• Sponge each area (part) for 2-3 min changing the wash cloth
• The sponge bath should take about 30 minutes
• Reassess v/s at the end
• Discontinue the bath if the clients becomes pale or cyanotic or shivers, or if the PR becomes
rapid or irregular
Temperature of hot water bottle (bag) 52 o
 For normal adults,40.5 – 46 oc– for debilitated (unconscious patients).
40.5-46 oc for children < 2 yrs;
Fill the bag about 2/3 full;
Expel the remaining air and secure the top;
Maximum effect occurs in 20-30 min;
The application is repeated Q2 – 3 hrs to relieve swelling compress
– a moist gauze or cloth immersed in (hot or cold) water and applied over an area.
1.3 Local Application of Cold
Application of Cold
• Has systemic and local effect
• Can be applied to the body in two ways
1. Moist
2. Dry
1. Moist Cold
Cold compress
A cloth (padded gauze) is immersed in cold water and applied in area where we get large
superficial vessels
E.g. axilla and groin
Change the cloth when it becomes warm
Applied for 15-20 min
2. Dry Cold (Ice Bag)

• Ice kept in a bag
• Covered with cloth and applied on an area
• Temperature <150 C
Instruction: Say True if the statement is correct and False if it was Wrong
1. cold decrease prostaglandin's, which intensify the sensitivity of pain receptors (3 Point)
2. Systemic effects of Hot will produce a drop in blood pressure which predispose to
excessive peripheral vasodilatation. (3 Point)
3. Being pale or cyanotic or shivers is an indication to discontinue cold compress, (3 Point)
4. Cold compress be applied to the body in moist way only. (3 Point)
5. A cloth (padded gauze) is immersed in cold water and applied in area where we get large
superficial vessels (3 Point)

Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
4. ________________________________________________________________
5. ________________________________________________________________

Information Sheet 9 Basic patent care: Cold Compress
1.1 Mouth Care
Purpose
• To remove food particles from around and between the teeth
• To remove dental plaque to prevent dental caries
• To increase appetite
• To enhance the client‟s feelings of well-being
• To prevent sores and infections of the oral tissue
• To prevent bad odor or halitosis
Equipments
• Toothbrush (use the person‟s private item. If patient has none use of cotton tipped
applicator and plain water)
• Tooth paste (use the person‟s private item. If patient has none of use cotton tipped
applicator and plain water)
• Cup of water
• Emesis basin
• Towel
• Denture bowel (if required)
• Cotton tipped applicator, padded applicator
• Vaseline if necessary
Mouth care for unconscious patient
Position

• Side lying with the head of the bed lowered, the saliva automatically runs out by gravity
rather than being aspirated by the lungs or if patient's head can not be lowered, turn it to
one side: the fluid will readily run out of the mouth, where it can be suctioned
• Rinse the patient's mouth by drawing about 10 ml of water or mouth wash in to the
syringe and injecting it gently in to each side of the mouth
• If injected with force, some of it may flow down the clients throat and be aspirated into
the lung
Bath (Bathing and Skin Care)
It is a bath or wash given to a patient in the bed who is unable to care for himself/herself.
1. Cleansing bath: Is given chiefly for cleansing or hygiene purposes and includes:
• Complete bed bath: the nurse washes the entire body of a dependent patient in bed
• Self-help bed bath: clients confined to bed are able tobath themselves with help from the
nurse for washing the back and perhaps the face
• Partial bath (abbreviated bath): only the parts of the client‟s body that might cause
discomfort or odor, if neglected are washed the face, hands, axilla, perineum and back
(the nurse can assist by washing the back) omitted are the arms, chest, and abdomen.
• Tub bath: preferred to bed baths because it is easier to wash and rinse in a tub. Also used
for therapeutic baths
• Shower: many ambulatory clients are able to use shower
• The water should feel comfortably warm for the client
• People vary in their sensitivity to heat generally it should be 43-46 oc (110-115of)
• The water for a bed bath should be changed at least once
Before bathing a patient, determine
a. The type of bath the client needs
b. What assistance the client needs
c. Other care the client is receiving – to prevent undue fatigue
d. The bed linen required
Note: when bathing a client with infection, the caregiver should wear gloves in the presence of
body fluids or open lesion.

Principles
• Close doors and windows: air current increases loss of heat from the body by convection
• Provide privacy – hygiene is a personal matter & the patient will be more comfortable
• The client will be more comfortable after voiding and voiding before cleansing the
perineum is advisable
• Place the bed in the high position: avoids undue strain on the nurses back
• Assist the client to move near you – facilitates access which avoids undue reaching and
straining
• Make a bath mitt with the washcloth. It retains water and heat better than a cloth loosely
held
• Clean the eye from the inner canthus to the outer using separate corners of the wash cloth
– prevents transmitting micro organisms, prevents secretions from entering the
nasolacrmal duct
• Firm strokes from distal to proximal parts of the extremities increases venous blood
return
Purpose:
• To remove transient moist, body secretions and excretions, and dead skin cell
• To stimulate circulation
• To produce a sense of well being
• To promote relaxation, comfort and cleanliness
• To prevent or eliminate unpleasant body odors
• To give an opportunity for the nurse to assess ill clients
• To prevent pressure sores
Two categories of baths given to clients
 Cleansing
 Therapeutic
A. Bed Bath
Equipment
• Trolley

• Bed protecting materials such as rubber sheet and towels
• Bath blanket (or use top linen)
• Two bath towels
• Wash cloth
• Clean pajamas or gown
• Additional bed linens
• Hamper for soiled cloths
• Basin with warm water (43-460c for adult and 38-400c for children)
• Soap on a soap dish
• Hygienic supplies, such as, lotion, powder or deodorants (if required)
• Screen
• Lotion thermometer (if available)
Tub Bath
Typically, bathtubs are low in height to ease the process of getting in and out of the tub. Guide
rails are essential. Be sure to assist the client as necessary.
Equipment
• Bath blanket
• Bath mat
• Bath towel
• Soap
• Clean gown or pajama
• Clean bed linen
• Bath thermometer if available
• Disinfectant for cleansing the tub
Back care
Back Care (massage): includes the area from the back and shoulder to the lower buttocks
Purpose
• To relieve muscle tension

• To promote physical and mental relaxation
• To improve muscle and skin functioning
• To relieve insomnia
• To relax patient
• To provide a relieve from pain
• To prevent pressure sores (decubitus)
• To enhance circulation
Three Types of Massage Strokes
1. Effleurage: stroking the body
2. Light, circular friction and straight, dup, firm, strokes
3. Petrissape: kneading and making large quick pinches of the skin, tissue, and muscle
• Clean the back first
• Warm the massage lotion or oil before use by pouring over your hands: cold lotion may
startle the client and increase discomfort
1. Effleurage the entire back: has a relaxing sedative effect if slow movement and light pressure
re used
2. Petrissape first up the vertebral column and them over the entire back: is stimulating if done
quickly with firm presuree
• Assess: signs of relaxation and /or decreased pain (relaxed breathing, decreased muscles
tension, drowsiness, and peaceful affect)
⇒ Verbalizations of freedom from pain and tension
⇒ Areas or redness, broken skin, bruises, or other sings of skin breakdown
Note
• The duration of a massage ranges from 5-20 minutes
• Remember the location of bony prominence to avoid direct pressure over this areas
• Frequent positioning is preferable to back massage as massaging the back could possibly lead
to subcutaneous tissue degeneration.
NB. Backrub requires special skills as it might cause subcutaneous tissue degeneration; mainly in
elderly.
Equipment
• Basin of warm water
• Washcloth
• Towel
• Soap
• Skin care lotion
Information Sheet 10 Wound care
1.1 Introduction: wound is any disruption in the skins intactness. It may b accidental or
intentional such as abrasion (rubbing off the skin‟s surface); a puncture wound (stab wound); or
laceration (a wound with torn, ragged edges). A wound may be intentional, such as surgical
incision (a wound with clean edges). A wound that occurs accidentally is contaminated;
intentional wounds are made under sterile condition.
1.2 Wound healing
Wound healing differs according to how much tissue has been damaged. It occurs by first,
second, and third intention.
First intention healing occurs in wounds with minimal tissue loss, such as surgical incisions or
sutured wounds. Edges are approximated (close to each other); thus they seal together rapidly.
Scaring and infection rate with first intention healing are low.
Second intention healing occurs with tissue loss, such as in deep laceration, burns, and pressure
ulcers. Because edges don‟t approximate, openings fill with granulation tissue that is soft and
pinkish. Later, epithelial cells grow over the granulation greater than that for first intention
healing.
Third intention healing occurs when there is a delay in the time between the injury and closure
of the wound. For example, a wound may be left open temporarily to allow for drainage or
removal of infectious materials. This type of healing some times occurs after surgery, when the
wound closes later. In the mean time, wound surfaces start to granulate. Scaring is common.
1. Dressing of a Clean Wound
Purpose
• To keep wound clean
• To prevent the wound from injury and contamination
• To keep in position drugs applied locally
• To keep edges of the wound together by immobilization
• To apply pressure
Equipment
• Pick up forceps in a container
• Sterile bowl or kidney dish
• Sterile cotton balls
• Sterile galipot
• Sterile gauze
• Three sterile forceps
• Rubber sheet with its cover
• Antiseptic solution as ordered
• Adhesive tape or bandages
• Scissors
• Ointment or other types of drugs as needed
• Receiver
• Spatula if needed
• Benzene or ether.
2. Dressing of Septic Wound
The purpose is to
• Absorb materials being discharge from the wound
• Apply pressure to the area
• Apply local medication
• Prevent pain, swelling and injury
Equipment
• Sterile galipot
• Sterile kidney dish
• Sterile gauze
• Sterile forceps 3
• Sterile test tube or slide
• Sterile cotton- tipped application
• Sterile pair of gloves, if needed, in case of gas gangrene rabies etc.
• Rubber sheet and its cover
• Local medication if ordered
• Spatula
• Receiver with strong disinfectant to immerse used instrument
• Probe and director if required
• Scissors
• Benzene or ether
• Bandages or adhesive tape
• Bucket to put in soiled dressing
N.B.
• If sterile forceps are not available, use sterile gloves
• Immerse used forceps, scissors and other instrument in strong antiseptic solution before
cleansing and discard soiled dressing properly.
• In a big ward it is best to give priorities to clean wounds and then to septic wounds, when
changing dressings, as this night lessen the risk of cross infection.
• Consideration should be given to provide privacy for the patient while dressing the
wound.
• Wounds should not be too tightly packed in effort to absorb discharge as this may delay
healing.
4. Dressing with Drainage Tube
Purpose
• Aids to prevent haematoma or collection of fluid in the affected area.
Equipment
• Sterile gallipot
• Sterile Scissors
• 3 Sterile forceps
• Sterile gauze
• Anti septic solution as ordered
• Sterile safety pins if needed
• Cotton wool or absorbent
• Receiver
• Adhesive tape or bandage
• Ointment paste or paraffin gauze
• Spatulas if needed
• One pair sterile gloves if available.
Note.
• Safe method should be used for disposing old dressing.
• Gauze and cotton used for cleaning wound.
• Take preventive measures to avoid skin irritation and excoriation.
• If drainage tube is attached to the bottle precaution must be taken to secure the tube in
place and avoid the risk of cross infection.
1.3 Wound Irrigation
Purpose
• To cleans and maintain. Free drainage of infected wounds.
Equipment
• Sterile galipot or kidney dish
• Sterile gauze
• 3 Sterile forceps
• Sterile catheter
• Sterile syringe 20 cc
• 2 receiver
• Solutions (H2O2 or normal saline are commonly used)
• Bandage scissors
• Receiver for soiled dressings
Note:
• Keep patient in a convinent position. According to the need so that solution will flow
from wound down to the receiver.
• Use sterile technique and warn solution for irrigating the wound.
1.4 Suturing
• Definition: The application of stitch on body tissues with the surgical needle & thread.
Purpose
• To approximate wound edges until healing occurs
• To speed up healing of wound
• To minimize the chance of infection
• For esthetic purpose
Equipment
• Tray or trolley covered with a sterile towel
• Sterile needle holder
• Sterile round needle (2)
• Sterile cutting needle (2)
• Sterile silk
• Sterile cat- gut
• Sterile tissue forceps
• Sterile suture scissors
• Sterile cotton swabs in a galipots
• Sterile solution for cleaning
• Sterile dressing forceps
• Sterile receiver
• Sterile gauze
• Sterile plaster
• Local anesthesia
• Sterile needle & syringes
• Sterile gloves
• Sterile hole- towel (Fenestrated towel)
Note:
• Do not suture wounds that are over 12 hrs old. How ever, such wounds have to be seen
by a doctor since excision of all dead & devitalized tissue and eventual suturing may be
required.
• Check that the patient gets his order for T.A.T before he leaves the hospital.
• Do not suture deep wound.
• Before you suture any wound, make sure it is free of any foreign bodies.
Fug 1: Suturing
1.5 Removal of the Stitch
Principles
• Sutures may be removed all at a time or may be removed alternatively.
• Do not cut stitches in more than one place as a part of it may be left behind and may
cause infection.
• Suture is lifted slightly by the knot to allow scissors to go under and one part of the
suturing from the cleanest part of the wound to the most contaminated part.
• Cleanse the skin around with antiseptic. Remove – gum with benzene or ether and
discard the forceps
• Place sterile gauze to receive stitches.
• Take a pair of scissors in the right hand.
• Take a dissecting forceps in the left hand.
• Pull-up gently the knot resting against the skin with the forceps, pass the point of the
scissors under the knot then cut the stitch on one side and remove.
• Receive pieces of stitches on a sterile gauze
• Inspect the scar for wound healing and apply iodine on the skin punctures if patient is not
sensitive to iodine.
• Apply dressing
• Keep patient comfortable and tide
• Record the state of the wound
• Clean and return equipment to their proper places.
1.6 Clips
Definition: Metal suture used to stitch the skin
Purpose
• Some as suturing with stitch
Equipment
• Michel clip applier
• Clip
• Tissue forceps (toothed dissecting forceps)
• Cleaning material- same as stuttering with stitch.
Procedure
The first part of procedure is the same as for suturing with stitch Except that instead of suturing
the skin with thread and needle you would apply clips with the applier.
Removal of Clips
Technique
Use aseptic technique
Equipment
• Sterile gauze
• Sterile forceps 3
• Sterile clip removal forceps
• Antiseptic solution (Savalon 1% and iodine)
• Receiver
• Benzene or ether
1. Identify different types of wound care. (4 Point)

2. Mention three types of wound healing intentions. (4 Point)
3. Mention the purposes of septic wound dressing. (4 Point)
4. Describe suturing. (4 Point)
5. What is clip? (4 Point)

Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
1. ________________________________________________________________
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2. ________________________________________________________________
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3. ________________________________________________________________
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4. ________________________________________________________________
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5. ________________________________________________________________
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Information Sheet 11 Perineal Care (Perineal – Genital Care)
1.1 Perineal Area:
• Is located between the thighs and extends from the symphysis pubis of the pelvic bone
(anterior) to the anus (posterior).
• Contains sensitive anatomic structures related to sexuality, elimination and reproduction
1.2 Perineal Care (Hygiene)
• Is cleaning of the external genitalia and surrounding area
• Always done in conjunction with general bathing
1.3 Patients in special needs of perineal care
• Post partum and surgical patients (surgery of the perineal area)
• Non surgical patients who unable to care for themselves
• Patients with catheter (particularly indwelling catheter)
Other indications for perineal care are:
1. Genito- urinary inflammation
2. Incontinence of urine and feces
3. Excessive secretions or concentrated urine, causing skin irritation or excoriation
1.4 Purpose
• To remove normal perineal secretions and odors
• To prevent infection (e.g. when an indwelling catheter is in place)
• To promote the patient's comfort
• To facilitate wound healing process
Equipments
• Bath towel
• Cotton balls and gauze squares
• Pitcher with worm water or/and prescribed solution in container
• Gloves
• Bed pan
• Bed protecting materials
• Perineal pad or dressing (if needed)
1.5 Male Perineum
• The penis contains pathways for urination and ejaculation through the urethral orifice
(meatus)
• At the end of the penis is the glans covered by a skin flap (fore skin or prepuce)
• The urethral orifice is located in the center of the penis and opens at the tip
Note
• Following genital or rectal surgery, sterile supplies may be required for cleaning the
operative site, E.g. Sterile cotton balls
• The operative site and perineal area may be washed with an antiseptic solution – apply
by squirting them on the perineum from a squeeze bottle
1.6 Care
• Hold the shaft of the penis firmly with one hand and the wash cloth with the other – to
prevent erection – embarrassment
• Use a circular motion, cleaning from the center to theperiphery
• Use a separate section of the wash cloth
1.7 Position
• Lying in bed with knee flexed to clean the perineal part andside lying cleaning the
perineal area
N.B: The urethral orifice is the cleanest area and the anal orifice isthe dirtiest area – always
stroke from front to back to wash from „clean‟ to „dirty‟ parts
Note: Entry of organisms into the urethral orifice can cause UTI
1.8 Caring for fingernails and toenails
• Definition: Nail cutting that one of nursing care and general care for personal hygiene is
to cut nails on hands and foots.
Purpose:
1. To keep nails clean
2. To make neatness
3. To prevent the client‟s skin from scratching
4. To avoid infection caused by dirty nail
Equipment required
1. Nail Cutter (1)
2. Gallipot with water (1): for cotton
3. Kidney tray (1)
4. Sponge cloth (1)
5. Middle towel (1)
6. Mackintosh (1)
7. Plastic bowl in small size (1)
8. Soap with soap dish (1).
1.9 Hair Care
• Hair care usually done after the bath and as daily hygienic activities in a daily base. Hair
care includes combing (brushing of hair), washing/shampooing of hair and pediculosis
treatment.
1.10 Combing/Brushing of Hair
• A patient hair should be combed and brushed daily most patients do this themselves if the
required materials provided and others may need nurse's help (assistance)
Purpose
• Stimulates the blood circulation to the scalp
• Distribute hair oils evenly and provide a healthy sheem
• Increase the patient's sense of well-being.
Equipments
• Comb (which is large with open and long toothed)
• Hand mirror
• Towel
• Lubricant/oils (if required)
1. Define perinal care (3 point)
2. Mention the function of perinal care (3 point)
3. List the importance of hair care (3 point)
4. Describe method of finger and toe nail care (3 point)
5. List the function of combing/Brushing of Hair (3 point)

You can ask you teacher for the copy of the correct answers
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Rating: ____________
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Information Sheet 12 Advanced patient care
1.1 Colostomy: A colostomy is an operation to divert one end of the colon (part of the bowel)
through an opening in the tummy.
The opening is called a stoma. A pouch can be placed over the stoma to collect your poo (stools).
A colostomy can be permanent or temporary.
When a colostomy is needed
A colostomy may be needed if, as the result of an illness, injury or problem with your digestive
system, you can't pass stools through your anus.
You may have a colostomy to treat:
 bowel cancer
 Crohn's disease
 diverticulitis
 anal cancer
 vaginal cancer or cervical cancer
 bowel incontinence
 Hirschsprung's disease
A colostomy is often used after a section of the colon has been removed and the bowel can't be
joined back together.
This may be temporary and followed by another operation to reverse the colostomy at a later
date, or it may be permanent.
How a colostomy is carried out
A colostomy is carried out under general anaesthetic using either:
 open surgery (laparotomy) – where a long cut (incision) is made in the tummy to access
the colon, or
 laparoscopic (keyhole surgery) – where the surgeon makes several smaller incisions
and uses a tiny camera and surgical instruments to access the colon
Generally, keyhole surgery is the preferred option because recovery is quicker and the risk of
complications is lower.
There are two main types of colostomy: a loop colostomy and an end colostomy. The specific
technique used will depend on your circumstances.
A loop colostomy is often used if the colostomy is temporary as it's easier to reverse.
1.2 Loop colostomy
In a loop colostomy, a loop of colon is pulled out through a cut in your tummy. The loop is
opened up and stitched to your skin to form an opening called a stoma.
The stoma has two openings that are close together. One is connected to the functioning part of
your bowel, where waste leaves your body after the operation.
The other opening is connected to the "inactive" part of your bowel, leading to your rectum.
In some cases, a support device (a rod or bridge) may be used to hold the loop of colon in place
while it heals. It's usually removed after a few days.
1.3 End colostomy
With an end colostomy, one end of the colon is pulled out through a cut in your tummy and
stitched to the skin to create a stoma.
An end colostomy is often permanent, but temporary end colostomies are sometimes used in
emergencies to treat bowel obstructions, colon injuries or bowel cancer.
1.4 The stoma
The position of the stoma will depend on the section of your colon that's diverted, but it's usually
on the left-hand side of your tummy, below your waist.
If the operation is planned in advance, you'll meet a specialist stoma nurse to discuss the
positioning of the stoma.
The stoma will be red and moist and may bleed slightly, particularly in the beginning – this is
normal. It shouldn't be painful as it doesn't have a nerve supply.
Stomas can vary in shape and size – some are fairly flat, while others protrude slightly.
1.5 Recovering from a colostomy
After having a colostomy, you'll need to recover in hospital for a few days.
You may have:
 a drip in your vein to provide fluids
 a catheter to drain urine from your bladder
 an oxygen mask to help you breathe
A clear colostomy bag will be placed over the stoma so it can be easily monitored and drained.
The first bag is often quite large – it'll usually be replaced with a smaller bag before you go
home.
1.6 Going home
Most people are well enough to leave hospital 3 to 10 days after having a colostomy.
Once home, avoid strenuous activities that could place a strain on your abdomen, such as lifting
heavy objects.
Your stoma nurse will give you advice about how soon you can go back to normal activities.
In the first few weeks after your operation, you may have more wind than usual (flatulence), and
a discharge from your stoma.
This should start to improve as your bowel recovers from the effects of the operation.
1.7 Tracheotomy
1.7.1 Introduction: Airway access for mechanical ventilation can be provided either by a trans
laryngeal endotracheal or tracheostomy tube.
During episodes of acute respiratory failure, patients are generally ventilated through an
endotracheal tube.
Changing to a tracheostomy tube is often considered when the need for mechanical ventilation is
expected to be prolonged.
Tracheostomy is a utilitarian surgical procedure of access; therefore, it should be discussed in
light of the problem it addresses: access to the tracheobronchial tree.
The trachea is a conduit between the upper airway and the lungs that delivers moist warm air and
expels carbon dioxide and sputum.
Failure or blockage at any point along that conduit can be most readily corrected with the
provision of access for mechanical ventilators and suction equipment.
In the case of upper airway obstruction, tracheostomy provides a path of low resistance for air
exchange.
1.7.2 Indications:
General indications include the following:
 Congenital anomaly (eg, laryngeal hypoplasia, vascular web)
 Upper airway foreign body that cannot be dislodged with Heimlich and basic cardiac life
support maneuvers
 Supraglottic or glottic pathologic condition (eg, infection, neoplasm, bilateral vocal cord
paralysis)
 Neck trauma that results in severe injury to the thyroid or cricoid cartilages, hyoid bone,
or great vessels
 Subcutaneous emphysema
 Facial fractures that may lead to upper airway obstruction (eg, comminuted fractures of
the mid face and mandible)
 Upper airway edema from trauma, burns, infection, or anaphylaxis
 Prophylaxis (as in preparation for extensive head and neck procedures and the
convalescent period)
 Severe sleep apnea not amendable to continuous positive airway pressure devices or other
less invasive surgery
Tracheostomy may also be performed to provide a long-term route for mechanical ventilation in
cases of respiratory failure or to provide pulmonary toilet in the following cases:
 Inadequate cough due to chronic pain or weakness
 Aspiration and the inability to handle secretions
1.7.3 Contraindications
No absolute contraindications exist for tracheostomy.
A strong relative contraindication to discrete surgical access to the airway is the anticipation that
the blockage is a laryngeal carcinoma.
The definitive procedure (usually a laryngectomy) is planned, and prior manipulation of the
tumor is avoided because it may lead to increased incidence of stomal recurrence.
The following patients are commonly recognized to be unfavorable candidates:
 Patients with obesity
 Patients with abnormal or poorly palpable midline neck anatomy
 Patients who need emergency airways
 Patients with coagulopathy
 Pediatric patients
 Patients with enlarged thyroids
1.7.4 Complication prevention
Potential complications are due to direct injury.
Bedside ultrasound is often used to survey the tracheostomy site during the planning stage,
especially for percutaneous tracheostomies.
This is to identify vessels that may be under the intended incision and to help avoid injury.
1.8 Lumbar puncture
1.8.1 Introduction
Lumbar puncture is a procedure that is often performed in the emergency department to obtain
information about the cerebrospinal fluid (CSF).
Although usually used for diagnostic purposes to rule out potential life-threatening conditions
(eg, bacterial meningitis or subarachnoid hemorrhage), it is also sometimes used for therapeutic
purposes (eg, treatment of pseudotumor cerebri).
CSF fluid analysis can also aid in the diagnosis of various other conditions (eg, demyelinating
diseases and carcinomatous meningitis).
Lumbar puncture should be performed only after a neurologic examination but should never
delay potentially life-saving interventions, such as the administration of antibiotics and steroids
to patients with suspected bacterial meningitis.
Relevant Anatomy
The lumbar spine consists of 5 moveable vertebrae numbered L1-L5.The lumbar vertebrae have
a vertical height that is less than their horizontal diameter. They are composed of the following 3
functional parts:
 The vertebral body, designed to bear weight
 The vertebral (neural) arch, designed to protect the neural elements
 The bony processes (spinous and transverse), which function to increase the efficiency of
muscle action
The lumbar vertebral bodies are distinguished from the thoracic bodies by the absence of rib
facets. The lumbar vertebral bodies (vertebrae) are the heaviest components, connected together
by the intervertebral discs. The size of the vertebral body increases from L1 to L5, indicative of
the increasing loads that each lower lumbar vertebra absorbs. Of note, the L5 vertebra has the
heaviest body, smallest spinous process, and thickest transverse process.
For more information about the relevant anatomy, see Lumbar Spine Anatomy.
1.8.2 Indications
Lumbar puncture should be performed for the following indications:
 Suspicion of meningitis
 Suspicion of subarachnoid hemorrhage (SAH)
 Suspicion of central nervous system (CNS) diseases such as Guillain-Barré syndrome [6]
and carcinomatous meningitis
 Therapeutic relief of pseudotumor cerebri [7]
Absolute contraindications for lumbar puncture are the presence of infected skin over the needle
entry site and the presence of unequal pressures between the supratentorial and infratentorial
compartments. The latter is usually inferred from the following characteristic findings on
computed tomography (CT) of the brain:
 Midline shift
 Loss of suprachiasmatic and basilar cisterns
 Posterior fossa mass
 Loss of the superior cerebellar cistern
 Loss of the quadrigeminal plate cistern
Relative contraindications for lumbar puncture include the following:
 Increased intracranial pressure (ICP)
 Coagulopathy
 Brain abscess
Indications for performing brain CT scanning before lumbar puncture in patients with suspected
meningitis include the following
 Patients who are older than 60 years
 Patients who are immunocompromised
 Patients with known CNS lesions
 Patients who have had a seizure within 1 week of presentation
 Patients with an abnormal level of consciousness
 Patients with focal findings on neurologic examination
 Patients with papilledema seen on physical examination, with clinical suspicion of an
elevated ICP
Cranial CT scanning should be obtained before lumbar puncture in all patients with suspected
SAH in order to diagnose obvious intracranial bleeding or any significant intracranial mass effect
that might be present in awake and alert SAH patients with a normal neurologic examination.
1.8.4 Complication prevention
The following measures should be taken to help minimize complications of lumbar puncture:
 Explain the procedure, benefits, risks, complications, and alternative options to the
patient or the patient‟s representative, and obtain a signed informed consent
 Before performing the lumbar puncture, ensure that patients are hydrated so as to avoid a
dry tap
 Never allow a lumbar puncture or a pre–lumbar puncture CT scan to delay administration
of intravenous (IV) antibiotics; meningitis can usually be inferred from the cell count,
antigen detection, or both
 Avoid lumbar puncture in patients in whom the disease process has progressed to the
neurologic findings associated with impending cerebral herniation (ie, deteriorating level
of consciousness and brainstem signs that include pupillary changes, posturing, irregular
respirations, and very recent seizure)
1.8.5 Equipment
A spinal or lumbar puncture tray (see the image below) should include the following items:
 Sterile dressing
 Sterile gloves
 Sterile drape
 Antiseptic solution with skin swabs
 Lidocaine 1% without epinephrine
 Syringe, 3 mL
 Needles, 20 and 25 gauge
 Spinal needles, 20 and 22 gauge
 Three-way stopcock
 Manometer
 Four plastic test tubes, numbered 1-4, with caps
 Syringe, 10 mL (optional)
1.8.6 Patient Preparation

Local anesthesia is employed for lumbar puncture (see Technique and Local Anesthetic Agents,
Infiltrative Administration).
The patient is placed in the lateral recumbent position (see the image below) with the hips, knees,
and chin flexed toward the chest so as to open the interlaminar spaces. A pillow may be used to
support the head. In a single-center prospective study, performance of lumbar puncture in the
extended rather than the flexed lateral recumbent position yielded a statistically significant
decrease in the cerebrospinal fluid (CSF) opening pressure, but the difference (mean, 0.6 ± 2.2
cm water) was small and of doubtful clinical significance.
The sitting position (see the image below) may be a helpful alternative, especially in obese
patients, because it makes it easier to confirm the midline. In order to open the interlaminar
spaces, the patient should lean forward and be supported by a Mayo stand with a pillow on it, by
the back of a stool, or by another person.
If the procedure is performed with the patient in the sitting position and an opening pressure is
required (as in the case of pseudotumor cerebri), replace the stylet and have an assistant help the
patient into the left lateral recumbent position. There are no data suggesting that a position
change will increase the risk of spinal headache or transection of the spinal nerves. Take care,
however, not to change the orientation of the spinal needle during this maneuver.
Lumbar Puncture
Wearing nonsterile gloves, locate the L3-L4 interspace by palpating the right and left posterior
superior iliac crests and moving the fingers medially toward the spine (see the image below).
Palpate that interspace (L3-L4), the interspace above (L2-L3), and the interspace below (L4-L5)
to find the widest space. Mark the entry site with a thumbnail or a marker. To help open the
interlaminar spaces, ask the patient to practice pushing the entry site area out toward the
practitioner.
Open the spinal tray, change to sterile gloves, and prepare the equipment. Open the numbered
plastic tubes, and place them upright (see the image below). Assemble the stopcock on the
manometer, and draw the lidocaine into the 10-mL syringe.
CSF collection tubes. Image courtesy of Gil Z Shlamovitz, MD.
Use the skin swabs and antiseptic solution to clean the skin in a circular fashion, starting at the
L3-L4 interspace and moving outward to include at least 1 interspace above and 1 below (see the
video below). Just before applying the skin swabs, warn the patient that the solution is very cold;
application of an unexpectedly cold solution can be unnerving for the patient.\
1.9 Postural Drainage
1.9.1 What is postural drainage?
Postural drainage sounds complicated, but it‟s really just a way to use gravity to drain mucus out
of your lungs by changing positions. It‟s used to treat a variety of conditions, including chronic
diseases such as cystic fibrosis and bronchiectasis, as well as temporary infections, such as
pneumonia.
The goal is to move mucus into the central airway, where it can be coughed up. It‟s safe for
people of all ages and can be done either at home or in a hospital or nursing facility.
Postural drainage is often done at the same time as percussion, sometimes called clapping, which
involves someone clapping on back, chest, or sides with a cupped hand in order to shake mucus
loose from the lungs.
These techniques, along with vibration, deep breathing, and huffing and coughing, are referred to
as chest physiotherapy, chest physical therapy, or airway clearance therapy.
1.9.2 General guidelines
 Each position should be held for a minimum of five minutes.
 Positions can be done on a bed or on the floor.
 In each position, your chest should be lower than your hips to allow mucus to drain.
 Use pillows, foam wedges, and other devices to make yourself as comfortable as
possible.
 While in the positions, try to breathe in through your nose and out through your mouth
for longer than you breathe in for maximum effectiveness.
 Do these positions in the morning to clear mucus that‟s built up overnight or right before
bed to prevent coughing during the night.
1.9.3 Does postural drainage work
• Several studies have been done on general chest physiotherapy, but very few specifically
address postural drainage.
• A review of published studies found that chest physiotherapy techniques provided short-
term relief for people with cystic fibrosis but didn‟t have any long-term effects.
• Another study found that the active cycle of breathing techniques may be more effective
than postural drainage for people with bronchiectasis.
• For people with pneumonia, a review of studies suggested that postural drainage isn‟t an
effective treatment method. However, the authors noted that most of the available studies
were done 10 to 30 years ago, and chest physiotherapy techniques have come a long way
since then.
• More research is needed to know how effective postural drainage really is. In the
meantime, your doctor may be able to suggest postural drainage positions or other chest
physiotherapy techniques that may work for you. They can also refer you to a respiratory
therapist or physical therapist who specializes in chest physiotherapy.
1.9.4 Are there any risks associated with postural drainage?
• Vomiting if postural drainage performed right after eating.
• Try to do the positions before eating or 1 1/2 to 2 hours after a meal.
• If left untreated, mucus in the lungs can turn into a serious condition, so make sure to
follow up to doctor if decide to try postural drainage. It may need additional treatment.
• Mucus in the lungs can also be a sign of an underlying condition that needs medical
treatment, such as chronic pulmonary obstructive disease (COPD).
1.9.5 When to call a doctor
Get emergency treatment if you have any of the following symptoms during or after postural
drainage:
 shortness of breath
 trouble breathing
 confusion
 skin that turns blue
 coughing up blood
 severe pain
1.10 Thoracentesis
1.10.1 What is a thoracentesis?
Thoracentesis, also known as a pleural tap, is a procedure done when there‟s too much fluid in
the pleural space.
This allows a pleural fluid analysis to be performed in the lab to figure out the cause of fluid
accumulation around one or both of the lungs.
The pleural space is the small space between the lungs and the chest wall.
This space typically contains approximately 4 teaspoons of fluid. Some conditions can cause
more fluid to enter this space.
These conditions include:
 cancer tumors
 pneumonia or other lung infection
 congestive heart failure
 chronic lung diseases
This is called pleural effusion. If there‟s excess fluid, it can compress the lungs and cause
difficulty breathing.
The goal of a thoracentesis is to drain the fluid and make it easier for you to breathe again.
In some cases, the procedure will also help your doctor discover the cause of the pleural effusion.
The amount of fluid drained varies depending on the reasons for performing the procedure.
It typically takes 10 to 15 minutes, but it can take longer if there‟s a lot of fluid in the pleural
space.
It may also perform a pleural biopsy at the same time, to get a piece of tissue from the lining of
your inner chest wall.
Abnormal results on a pleural biopsy can indicate certain causes for the effusion, including:
 the presence of cancer cells, such as lung cancer
 mesothelioma, which is an asbestos-related cancer of the tissues that cover the lungs
 collagen vascular disease
 viral or fungal diseases
 parasitic disease
1.10.2 Preparing for a thoracentesis
There‟s no special preparation for a thoracentesis. However, you should talk to your doctor if
you have any questions or concerns about the procedure. You should also tell your doctor if you:
 are currently taking medications, including blood thinners like aspirin, clopidogrel
(Plavix), or warfarin (Coumadin)
 are allergic to any medications
 have any bleeding problems
 may be pregnant
 have lung scarring from previous procedures
 currently have any lung diseases like lung cancer or emphysema
1.10.3 What is the procedure for a thoracentesis?
Thoracentesis can be done in a doctor‟s office or in a hospital. It‟s typically done while patents
awake, but he may be sedated.
After sitting in a chair or lying on a table, patents will be positioned in a way that allows the
doctor to access the pleural space.
An ultrasound may be done to ascertain the correct area where the needle will go.
The selected area will be cleaned and injected with a numbing agent.
Your doctor will insert the needle or tube below your ribs into the pleural space.
You might feel an uncomfortable pressure during this process, but you should keep very still.
The excess fluid will then be drained out.
Once all the fluid is drained, a bandage will be put on the insertion site.
To ensure there are no complications, patents may be asked to stay overnight in the hospital to be
monitored.
A follow-up X-ray may be performed right after the thoracentesis.
1.10.4 What are the risks of the procedure?
Every invasive procedure has risks, but side effects are uncommon with thoracentesis. Possible
risks include:
 pain
 bleeding
 air accumulation (pneumothorax) pushing on the lung causing a collapsed lung
 infection
Your doctor will go over the risks before the procedure.
Thoracentesis is not an appropriate procedure for everyone. Your doctor will determine if you‟re
a good candidate for thoracentesis. People who‟ve had recent lung surgery may have scarring,
which can make the procedure difficult.
People who should not undergo thoracentesis include people:
 with a bleeding disorder
 taking blood thinners
 with heart failure or enlargement of the heart with trapped lung
1.10.5 Following up after the procedure

After the procedure is over, patents vitals will be monitored, and he may have an X-ray of
patents lungs taken. Patents will allow go home if his breathing rate, oxygen saturation, blood
pressure, and pulse are all good.
Most people who have a thoracentesis can go home the same day.
Patents will be able to return to most of his normal activities soon after the procedure. However,
doctor may recommend that patents avoid physical activity for several days after the procedure.
Doctor will explain how to take care of the puncture site.
Make sure to call doctor if patents begin to have any signs of infection.
Symptoms of infection include:
 trouble breathing
 coughing up blood
 fever or chills
 pain when you take deep breaths
 redness, pain, or bleeding around the needle site
1.11 Paracentesis
1.11.1 Background
Paracentesis is a procedure in which a needle or catheter is inserted into the peritoneal cavity to
obtain ascitic fluid for diagnostic or therapeutic purposes.
Ascitic fluid may be used to help determine the etiology of ascites, as well as to evaluate for
infection or presence of cancer.
Causes of transudative ascites include the following:
 Hepatic cirrhosis
 Alcoholic hepatitis
 Heart failure
 Fulminant hepatic failure
 Nephrotic syndrome
 Portal vein thrombosis
Causes of exudative ascites include the following:

 Peritoneal carcinomatosis
 Inflammation of the pancreas or biliary system
 Peritonitis
 Ischemic or obstructed bowel
An alternative way of differentiating ascites due to portal hypertension from that due to other
causes is to measure ascitic fluid viscosity with a cutoff of 1.65.
1.12.2 Spontaneous bacterial peritonitis
Infection of ascitic fluid without intra-abdominal infection usually occurs in patients with
chronic liver disease due to translocation of enteric bacteria.
Common pathogens include Escherichia coli, Klebsiella pneumoniae, enterococcal species, and
Streptococcus pneumoniae.
1.12.3 Indications
Diagnostic tap is used for the following:
 New-onset ascites - Fluid evaluation helps to determine etiology, differentiate transudate
versus exudate, detect the presence of cancerous cells, or address other considerations
 Suspected spontaneous or secondary bacterial peritonitis
 Refractory ascites
Therapeutic tap is used for the following:
 Respiratory compromise secondary to ascites
 Abdominal pain or pressure secondary to ascites (including abdominal compartment
syndrome)
An acute abdomen that requires surgery is an absolute contraindication.
Other relative contraindications include the following:
 Pregnancy
 Distended urinary bladder
 Abdominal wall cellulitis
 Distended bowel
 Intra-abdominal adhesions
1.12.5 Patient Education and Consent
Explain the procedure, benefits, risks, complications, and alternative options to the patient or the
patient's representative, and obtain signed informed consent.
Equipment
The equipment required can be found in a disposable paracentesis/thoracocentesis kit (see the
image below).
Fig 1 Paracentesis/thoracocentesis tray.
Equipment includes the following:
 Antiseptic swab sticks
 Fenestrated drape
 Lidocaine 1%, 5-mL ampule
 Syringe, 10 mL
 Injection needles, 22-gauge (two)
 Injection needle, 25-gauge
 Scalpel, No. 11 blade
 Catheter, 8 French, over 18-gauge × 7.5-in. needle with three-way stopcock, self-sealing
valve, and a 5-mL Luer-Lok syringe
 Syringe, 60 mL
 Introducer needle, 20-gauge
 Tubing set with roller clamp
 Drainage bag or vacuum container
 Specimen vials or collection bottles (three)
 Gauze, 4 × 4 in.
 Adhesive dressing
1.12.6 Patient Preparation
Anesthesia
Local anesthesia with injection of lidocaine is employed.
Positioning
Patients with severe ascites can be positioned supine. Patients with mild ascites may need to be
positioned in the lateral decubitus position, with the skin entry site near the gurney. The lateral
decubitus position is advantageous because air-filled loops of bowel tend to float in a distended
abdominal cavity.
The two recommended areas of abdominal wall entry for paracentesis are as follows (see the
image below):
 2 cm below the umbilicus in the midline (through the linea alba)
 5 cm superior and medial to the anterior superior iliac spines on either side
1.12.7 Paracentesis Technique
Ensure that the patient's bladder is empty, either through voluntary emptying on the part of the
patient or through the use of a Foley catheter.
Position the patient, and prepare the skin around the entry site with an antiseptic solution (see the
first image below). Apply a sterile fenestrated drape to create a sterile field
1.12.8 Complications
Complications from paracentesis may include the following:
 Failed attempt to collect peritoneal fluid
 Persistent leak from the puncture site
 Wound infection
 Abdominal wall hematoma
 Spontaneous hemoperitoneum - This rare complication is due to mesenteric variceal
bleeding after removal of a large amount of ascitic fluid (>4 L).
 Hollow viscus perforation (small or large bowel, stomach, bladder)
 Catheter laceration and loss in abdominal cavity
 Laceration of major blood vessel (aorta, mesenteric artery, iliac artery)
 Postparacentesis hypotension
 Dilutional hyponatremia
 Hepatorenal syndrome
1. What is colostomy? (2 Point)
2. What are the indications for colostomy? (4 Point)
3. What are the contraindications for colostomy? (4 Point)
4. What is tracheostomy? (2 Point)
5. What are the indications for tracheostomy? (4 Point)
6. What are the contraindications for tracheostomy? (4 Point)
7. What is Lumbar puncture? (2 Point)
8. What are the indications for Lumbar puncture? (4 Point)
9. What are the contraindications for Lumbar puncture? (4 Point)
10. What is postural drainage? (2 Point)
11. What are the indications for postural drainage? (4 Point)
12. What are the contraindications for postural drainage? (4 Point)
13. What is Thoracentesis? (2 Point)
14. What are the indications for postural drainage? (4 Point)
15. What are the contraindications for postural drainage? (4 Point)
16. What is paracentesis? (2 Point)
17. What are the indications paracentesis? (4 Point)
18. What are the contraindications for paracentesis? (4 Point)
19. What are possible complications of paracentesis? (4 Point)
20. What is the major complication rate of paracentesis? (4 Point)

Answer Sheet
Score = ___________
Rating: ____________
Name: _________________________ Date: ____________
1. ________________________________________________________________
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2________________________________________________________________
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3________________________________________________________________
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4________________________________________________________________
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5________________________________________________________________
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6. ________________________________________________________________
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7________________________________________________________________
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8________________________________________________________________
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9________________________________________________________________
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10. ________________________________________________________________
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11.________________________________________________________________
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12 ________________________________________________________________
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13. ________________________________________________________________
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14________________________________________________________________
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15________________________________________________________________
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16. ________________________________________________________________
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17________________________________________________________________
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18________________________________________________________________
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19________________________________________________________________
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20. ________________________________________________________________
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List of Reference Materials
1. Gallagher, E.J. (2004) Nasogastric Tubes: Hard to swallow. Annals of Emergency

Medicine, 44(2), 138-141.
2. Metheny, A, N. & Titler, M. G. (2001). Assessing Placement of Feeding Tubes.
American Journal of Nursing, 101(5), 36-45.
3. Metheny, A, N. & Stewart, B. J. (2002). Testing feeding tubes placement during
continuous tube feedings. Applied Nursing Research, 15(4), 254-258.
4. The Joanna Briggs Institute. Nasogastric Tube Insertion and Management for adults.
(2009). (Retrieved 18/05/09). http://www.jbiconnect.org/acutecare/docs/cis/cb-html-
5. The Clinical Resource Efficiency Support Team. Guidelines for the management of
enteral tube feeding in adults. CREST. (2004). (Retrieved 01/01/09)
http://www.crestni.org.uk/publications/
6. National Patient Safety Agency. Nasogastric tube incidents, summary update. (2007).
(Retrieved 05/01/09) http://www.npsa.nhs.uk/patientsafety/alerts-and-
directives/alert/nasogastric-feeding-tubes
7. National Guideline Clearinghouse. pH Testing. Laboratory medicine practice guidelines:
Evidence based practice for point of care testing. (2006). (Retrieved
11/11/08).http://www.guideline.gov/summary
8. Williams, T. A. & Leslie, G. D. (2004). A review of the nursing care of enteral. Feeding
tubes in critically ill adults: part1. Intensive Care and Critical Care Nursing, 20(6), 336-
343
9. Williams, T. A. & Leslie, G. D. (2004). A review of the nursing care of enteral. Feeding
tubes in critically ill adults: part2. Intensive Care and Critical Care Nursing, 21(7), 5-15
10. Canterbury DHB Christchurch Hospitalauthoriser = director of nursing Volume A –
Policies and Procedures Nasogastric Tube Insertion Policy Authorised by: Director of
Nursing Ref. 0136 Issue Date: April 2013 Issue No: 2
11. Basic Clinical Nursing Skills LECTURE NOTES (2002) For Nursing Students Abraham
Alano,
Pripared By
Educational Phaone
No Name LEVEL Region College Email
Back grund Number
1 Middega Jbril Nursing B oromia Nagelle HSC midhagadhangago@gmail.com 0091318425
2 Biratu Ebessa Nursing A BGRS Pawi HSC biratuebs004@gmail.com 0915926607
3
Ali Adan Mohamed Nursing A Somali Jigjiga HSC alishide120@gmail.com 0912866022
4 Tariku Abebe Nursing A oromia Mettu HSC gessessetariku@gmail.com 0917831032
5
Birhanu Tessisa Nursing B oromia Nekemte HSC birhanutessisa3@gmail.com 0913327601
6 Eskender Birhanu Nursing B Harari Harar HSC amenaesender@gmail.com 0933259187
7
Ferhan Abubeker Nursing A Harari Harar HSC Feru_ab@yahoo.com 0915742083

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Nursing Level III

NTQF Level III

TTLM Code: HLT NUR3 M LO5 TTLM, 09

LO5. Apply basic patient/client

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Self-Check 1 Written Test

1. How many types of bed making do you know?

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Note: Satisfactory rating - 8 points Unsatisfactory - below 8 points

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Operation Sheet 1 Closed Bed

Step 1Wash hands and collect necessary materials

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Operation Sheet 2 Occupied Bed

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LAP Test Practical Demonstration

Name: _____________________________ Date: ________________

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2.1 Urinary Catheterization

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Operation Sheet 3 Catheterization

Step 1: Prepare the client and equipment for perennial wash

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Operation Sheet 4 Retention (Indwelling) Catheter

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LAP Test Practical Demonstration

Name: _____________________________ Date: ________________

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1. Define NG tube (2 Points)

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An X-ray must be obtained to confirm placement.

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Self-Check 4 Written Test

A. For emptying B. For diagnostic purpose

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A. Cleansing (evacuation) B. Retention

3. During provision of enema the amount of solution to be administered depends on (3 point)

A. Cleansing (evacuation) B. Retention

4. List purpose of providing enema (5 point)

Note: Satisfactory rating - 10 points Unsatisfactory - below 10 points

Name: _____________ Date:

Name: _____________ Date: