1
CLO#1: Define the following terms related to interventions for common signs and
symptoms
CLO#2: State the importance of: tepid sponge bath, chest tapping and ORESOL
preparation
CLO#3: Differentiate the types of: fever, cough and diarrhea
CLO#4: Identify the associated signs and symptoms of: fever, cough and diarrhea
CLO#5: Explain the following: principles and guidelines of tepid sponge bath, chest
tapping and ORESOL preparation
CLO#6: Discuss general guidelines and nursing interventions in the management of:
fever, cough and diarrhea
CLO#7: Show beginning skills in: tepid sponge bath, chest tapping and ORESOL
preparation
2
CLO#1: Define the following terms related to interventions for common
signs and symptoms.
1.1 Intervention - any treatment, based upon clinical judgment and knowledge, that
a nurse performs to enhance patient/client outcomes.
1.2 Sign - detectable by an observer or can be measured or tested against an
acceptable standard; can be seen, heard, felt, or smelled; also called objective data.
1.3 Symptom - information (data) apparent only to the person affected that can be
described or verified only by that person; also called subjective data.
1.4 Syndrome - a recognizable complex of symptoms and physical findings which
indicate a specific condition for which a direct cause is not necessarily understood.
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1.5 Fever - elevated body temperature.
1.6 Tepid Sponge Bath - involves the use of a sponge. Done for clients who are
febrile, helps in managing and controlling the hyperthermia.
1.7 Cough - is a voluntary or involuntary act that clears the throat and breathing
passage of foreign particles, microbes, irritants, fluids, and mucus; it is a rapid
expulsion of air from the lungs.
1.8 Chest physiotherapy – involves a number of physical techniques to help remove
excess mucus from respiratory passages and improve breathing. The goal is to help
patients breathe more freely and get more oxygen through the bloodstream into all
parts of the body. These therapies include chest percussion, vibration and postural
drainage.
•
Chest Percussion: clapping (percussion) by the nurse on the chest wall over the
part of the lung to be drained helps move the mucus into the larger airways. The hand
is cupped as if to hold water but with the palm facing down. The cupped hand curves
to the chest wall and traps a cushion of air to soften the clapping.
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•
Vibration: is a technique that gently shakes the mucus so it can move into the
larger airways. The nurse places a firm hand on the chest wall over the part of the
lung being drained and tenses the muscles of the arm and shoulder to create a fine
shaking motion. Then, the nurse applies a light pressure over the area being vibrated.
(The nurse may also place one hand over the other, then press the top and bottom
hand into each other to vibrate.) Vibration is done with the flattened hand, not the
cupped hand. Exhalation should be as slow and as complete as possible.
•
Postural Drainage: the person lies or sits in various positions so the part of the
lung to be drained is as high as possible. This technique uses gravity as an aid to
draining secretions by optimizing the position of the body to clear mucus.
1.9 Chest tapping - means that you lightly tap your chest and back. The tapping
loosens the mucus in your lungs.
1.10 Expectorant - a medication that helps bring up mucus and other material from
the lungs, bronchi, and trachea.
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1.11 Diarrhea - defecation of liquid feces and increased frequency of defecation.
1.12 Dehydration - insufficient fluid in the body.
1.13 Rehydration - the process of restoring lost water (dehydration) to the body
tissues and fluids.
1.14 Oral Rehydration Solution (ORESOL) – A solution used to prevent or correct
dehydration due to diarrheal illnesses. The World Health Organization recommends
that the solution contain 3.5 g sodium chloride; 2.9 g potassium chloride; 2.9 g
trisodium citrate; and 1.5 g glucose dissolved in each liter of drinking water.
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1.15 Oral Rehydration Therapy – the administration of fluid by mouth to prevent
or correct the dehydration that is a consequence of diarrhea.
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CLO#2: State the importance of: tepid sponge bath, chest tapping and
ORESOL preparation
2.1 Importance of Tepid Sponge Bath:
●
●
●
●
Helps reduce or decrease the body temperature.
Stimulates impulse through skin receptors.
Relieve the symptoms of cold.
Promote dispersal of body heat.
2.2 Importance of Chest tapping:
● Helps loosen the thick mucus in the lungs to the larger airways where it can be
coughed and/or suctioned out.
● Promotes expectoration with greater ease by loosening tenacious pulmonary
secretions from the bronchial walls.
2.3 Importance of ORESOL preparation:
● Treats dehydration caused by diarrhea.
● Helps the human body in maintaining electrolyte balance.
● Replace salts and water that the body loses when you have dehydration caused
by gastroenteritis, diarrhea, or vomiting.
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CLO#3: Differentiate the types of: fever, cough and diarrhea
3.1 Types of Fever
● Intermittent - Intermittent fever is uncommon during the course of infectious
infections, but it can be difficult to diagnose and treat. Focused bacterial infections,
primarily infections of canals such as the urinary or biliary ducts or the colon, as well
as infections of foreign material, are the most common infectious causes of
intermittent fever. Other causes include infective endocarditis, TB, Yersinia
enterocolitica infections, and malaria, as well as rare cases like borreliosis, rat bite
fever, chronic meningococcemia, and chronic Epstein-Barr Virus infection.
The temperature is only present for a few hours of the day within a 24-hour period,
and the rest of the time is normal. The surge can happen at the same time every day,
every other day, or every few days, but it usually follows a pattern.
● Remittent - A remittent fever is similar to a continuous fever since the person
sustains an elevated temperature for a period of 24 hours. The key difference is that
the temperature fluctuates by more than 1 degree Celsius and can go higher or lower.
The fever, on the other hand, progressively fades with time.
Infectious endocarditis is one of the most common causes of remittent fever. The
organ that borders the inside chambers of the heart is called endocarditis. Infective
endocarditis is a cardiac condition that arises when bacteria enters the body through
the bloodstream and infects this organ.
● Relapsing - A bacterial infection spread by a louse or tick causes relapsing fever. It
is characterized by recurrent fever bouts.
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There are two major forms of relapsing fever:
● Tick-borne relapsing fever (TBRF) is transmitted by the ornithodoros tick. It
occurs in Africa, Spain, Saudi Arabia, Asia, and certain areas in the western
United States and Canada. The bacteria species associated with TBRF are
Borrelia duttoni, Borrelia hermsii, and Borrelia parkeri.
● Louse-borne relapsing fever (LBRF) is transmitted by body lice. It is most
common in Asia, Africa, and Central and South America. The bacteria species
associated with LBRF is Borrelia recurrentis.
Sudden fever occurs within 2 weeks of infection.
● Constant - This form of fever occurs when your body temperature rises but just by
one degree above the normal temperature. The temperature does not fluctuate more
than 1 degree Celsius and remains high for more than 24 hours, hence the name
"continuous fever." This type of fever could also be a symptom or cause of something
more dangerous.
There are many illnesses that can cause continuous fever, these include:
● Pneumonia- A continuous fever could be a symptom of a bacterial infection
caused by pneumonia. This illness affects the lungs and can cause difficulty in
breathing and impair the flow of gas in the body.
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● UTI- A UTI or Urinary Tract Infection is caused by bacteria such as E.coli and
can result in continuous fever. A person who has this infection can face a lot of
discomfort when urinating.
● Typhoid- When a person consumes food that is infected with bacteria like
Salmonella, it can result in Typhoid. In addition to continuous fever a person
with the illness can also suffer from intestinal bleeding and an enlargement of
the liver.
3.2 Types of Cough
● Productive Cough - A productive cough produces phlegm or mucus (sputum).
The mucus may have drained down the back of the throat from the nose or
sinuses or may have come up from the lungs. A productive cough generally
should not be suppressed—it clears mucus from the lungs. Some possible
causes of a productive cough, Acute Bronchitis, Pneumonia, Cystic Fibrosis,
Gastroesophageal Reflux Disease (GERD), and Chronic Obstructive Pulmonary
Disease (COPD). Mucus may run down the back of the throat due to colds and
allergies (post-nasal drainage).
A productive cough is a more serious when:
● It produces sputum from the lungs (not post-nasal drainage).
● The sputum is rust-coloured or contains bright red blood.
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● It lasts longer than 10 days.
● It occurs with other symptoms. These may include, Fever and chills, Shortness
of breath, Chest pain, Night sweats, and Weight loss.
● Non-productive - Nonproductive cough, as contrast to productive cough, does not
produce any mucus or other secretions. It is caused by irritation in the throat, which
many people describe as a "scratchy" or "tickling" sensation, a nonproductive cough is
also known as a dry cough. A nonproductive cough may also be a sign of Flu,
Allergies, Coronavirus, Swollen Airways (due to Asthma and Bronchitis), and other
Upper-Respiratory Infections
3.3 Types of Diarrhea
● Acute - Acute diarrhea is defined as the abrupt onset of 3 or more loose stools per
day and lasts no longer than 14 days. Most cases of acute, watery diarrhea are caused
by viruses (viral gastroenteritis). The most common ones in children are rotavirus and
in adults are norovirus (this is sometimes called “cruise ship diarrhea” due to well
publicized epidemics) It's known as cruise ship diarrhea because outbreaks are
discovered and reported more quickly, and Norovirus can be spread through infected
people, contaminated food or water, or contact with contaminated surfaces.
● Chronic - Chronic or persistent diarrhea is defined as an episode that lasts longer
than 14 days. An underlying medical problem can sometimes induce chronic diarrhea.
Inflammatory bowel disease (IBD), also known as ulcerative colitis or Crohn's disease,
can cause chronic bloody diarrhea. Ischemia of the gut, infections, radiation therapy,
and colon cancer or polyps are some of the less prevalent reasons. With the exception
of parasites, infections that cause chronic diarrhea are uncommon.
Chronic diarrhea, on the other hand, is caused by infections, food allergies and
intolerances, digestive system difficulties, abdominal surgery, and long-term use of
medicines. Acute diarrhea, on the other hand, is caused by infections, travelers'
diarrhea, and medicine side effects.
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CLO#4: Identify the associated signs and symptoms of: fever, cough and
diarrhea
4.1 Associated signs of Fever
● A fever is a higher-than-normal body temperature. It's a sign of your body's
natural fight against infection. For adults, a fever is when your temperature is
higher than 100.4°F.
FEVER
Signs
●
●
●
●
●
●
●
Symptoms
Temperature (above 37.5°C)
Unintentional weight loss
Sweating
Dehydration, dry mouth
Chills and shivering
Flushed complexion
Skin feels warm/warm to touch
● Feeling excessively cold
● Not the same desire to eat as
used to
● Dizziness or lightheadedness
● Loss of appetite
● Fatigue
● Headaches
● Muscle aches
4.2 Associated signs of Cough
● A cough is a sudden, usually involuntary, expulsion of air from the lungs with a
characteristic and easily recognizable sound.
COUGH
Signs
● Runny or stuffy nose
● Wheezing
● Hoarseness, the voice sounds
raspy, strained or breathy
● A change in voice pitch
● High-pitched whistling sound
when breathing
Symptoms
● Sore throat, a pain, scratchiness
or irritation of the throat
● Discomfort/pain when swallowing
● Phlegm
● Sinus pressure
● Tightening of chest when
breathing
● Tickling feeling in your throat
● Constant urge to clear your throat
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4.3 Associated signs of Diarrhea
● Diarrhea is frequent, loose, and watery bowel movements. Bowel movements,
also called stools, are body wastes passed through the rectum and anus.
DIARRHEA
Signs
●
●
●
●
●
●
●
Fever
Dehydration
Frequent loose, watery stools
Bloating
Blood in stool
Mucus in stool
Vomiting
Symptoms
Nausea
Dizziness or lightheadedness
Pain in chest and pelvic regions
Fatigue
Watery, mushy, or shapeless
bowel
● Bowel with strong or foul odor
● Frequent urge to defecate
● Abdominal pain and cramps
●
●
●
●
●
14
CLO#5: Explain the following: principles and guidelines of tepid sponge
bath, chest tapping and ORESOL preparation
Principles involved in Tepid Sponge Bath
Anatomy and Physiology - Involves all body parts by washing with warm water to
decrease body temperature and promote circulation of blood. Apply the tepid sponge
bath to the forehead and nape of neck. High heat areas also include armpits and groin.
Body Mechanics - In performing the procedure, correct posture and locomotive
movements must be done to make the cleansing more efficient to avoid injury.
Microbiology - Performing tepid sponge bath cleanses the patient of dirt and
microorganisms in his/her body and prevents nosocomial infection. All materials should
be cleaned or washed to maintain cleanliness.
Psychology - Patients who have not cleaned themselves after a few days of
admission would feel embarrassed and ashamed to interact with the people around
them but when the patient receives the tepid sponge bath, they would feel more
refreshed and comfortable afterwards due to the fact that they are now clean.
Physics - In doing the tepid sponge bath, massaging certain places like the scalp the
nurse must make sure that it is in a correct motion with the right pressure and force
applied to it. As for the skin, patting the parts with a circular motion must be
observed and always check the angle in doing so.
Safety and Security - Make sure the water is lukewarm, not hot and not cold. Drape
the client properly to promote privacy.
Sociology - Interact with the client to build good rapport.
Time and Energy - Prepare all the needed materials before performing the
procedure.
Principles involved in Chest Tapping
Anatomy and Physiology - Chest tapping helps to decrease work of breathing,
promote the expansion of the lungs, and prevent the lungs from collapse.
Knowledge on respiratory assessment is important to properly examine the
client and perform procedures correctly.
Body Mechanics - The nurse must observe proper body mechanics by keeping
shoulders, elbows and wrist relaxed during the maneuver. The bed level must be
adjusted to ensure proper body mechanics to avoid fatigue or injury to the
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nurse. The client must be in a comfortable or painless position to enhance the
efficacy of the procedure.
Microbiology - All materials should be cleaned to avoid transmission of
microorganisms. The equipment required is a thin towel and a drainage table. The
nurse must perform medical hand washing before and after the procedure. The nurse’s
cupped hands is used to deliver the force required to drain the thick or the retained
secretions.
Physics - Chest percussion is performed with cupped hands by trapping air between
the patient's thorax and caregiver's hand in an alternating rhythmic manner over the
lung segments in which the secretions are to be drained. This loosens the thick, sticky
secretions from the walls of the lung allowing them to move more freely into the larger
airways, especially when used with associated gravity positioning.
Psychology - Explain the procedure properly for the client to understand the process
and for him/her to feel less anxious.
Safety and Security - Drape the client to promote privacy.
Sociology - Build rapport with the patient for the client to cooperate actively in the
procedure. Communicate effectively throughout the course of care and engage the
client in his/her treatment.
Time and Energy - Prepare all the necessary materials for the procedure to save
time.
Principles involved in Oresol Preparation
Chemistry - Water should be in a modest amount of sugars and salt. To promote
optimal absorption, the composition of the rehydration solution is critical. The
proportion of sugars and salts must match what the body needs to recover.
Microbiology - All materials should be cleaned thoroughly. Maintain cleanliness as the
solution is prepared.
Psychology - The nurse must explain the procedure to the client for him/her to feel
less anxious. By informing the client, he/she will be guided on how much ORS to take
and how often to take it.
Sociology - Building rapport with the client will make it easier for them to participate
with the procedure.
Time and Energy - Prepare all the needed materials before doing the procedure.
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CLO#6: Discuss general guidelines and nursing interventions in the
management of fever, cough, and diarrhea
❖ General guidelines involved in Tepid Sponge Bath
1.
2.
3.
4.
5.
6.
7.
Assess the condition of your patient. This data will serve as a basis in evaluating
the patients’ response to the treatment.
Explain the method to the patient or the watcher. By providing the patient and
watcher some information about the procedure, it will be much easier for them
to cooperate.
Bring all equipment and set them in the area near the bed. Carefully check all of
your materials to make sure everything is there.
Wash hands thoroughly before starting the procedure to prevent the spread of
germs.
Close the door or the partition sheets (if at the ward) to provide privacy.
Adjust the patients' bed to a certain height that is accessible for working. This is
beneficial on your side as it protects you from straining your back.
Place the bed protector or rubber sheet on the patients' bed to protect bed
linens.
8.
9.
Put on your working gloves. This prevents the transmission of contaminants.
Carefully remove patients' clothing and place the bath blanket on top of him to
ensure privacy.
10.
Fill in your basin with cold water and mix it up with hot water. Make sure to
check its temperature. It should be neither too hot nor too cold. The
appropriate temperature is 27-37 degrees Celsius.
Immerse or dip small towels in the lukewarm water. Do this for about 20 to 30
minutes and repeat if necessary. Heat transfer is much more effective when
11.
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12.
13.
14.
15.
compresses are applied on areas with large superficial blood vessels such as the
axillary and groin areas.
Carefully wipe the patients' extremities for about 5 minutes. Then proceed with
the back and buttocks area for about 5-10 minutes. Abdomen and chest areas
are usually not included. Use long strokes for sponging and avoid circular
movements or it can cause friction while sponging.
Monitor the patients' response to the treatment by checking his temperature. If
it is slightly above normal, discontinue the procedure. Normal temperature is 37
degrees Celsius and abnormal is 38 degrees Celsius.
Replace the patients' clothing and cover him with a light sheet. As much as
possible, avoid letting your patient wear heavy clothing or excessive sheet
covering as it will only elevate his temperature.
Now begin aftercare by doing the following: change bed linens and remove the
equipment away from the bed to prevent transmission of microorganisms, lower
the patients' bed back to a safer height, Remove gloves, and wash your hands
thoroughly.
Removing or changing linens for an occupied bed include:
-
-
-
Remove soiled items ensuring not to shake the linens, as this can
introduce microorganisms into the air.
Change the fitted sheet. Gently rolling patients onto their side. Remove
the fitted sheet by rolling it towards the patient. Put a pad where the
patient’s hips will lie. Then roll clean linen towards you. Carefully roll the
patient onto the clean linen. Tucking the corners and sides is for the
safety of the patient and pulling the clean linen tightly on the bed will
prevent it from being wrinkled.
Use a draw sheet to allow you to move the patient side to side during the
process.
Remove top bedding and place a privacy blanket over the patient. Only
put the bed rail down on the side you’re working on for the safety of the
patient.
Remove the dirt pillowcases by unrolling it away from you. Change your
gloves to a clean pair after.
Put on a fresh pillowcase, put the clean pillowcase over your hand and
arm so that you can grasp the center of the pillow with the covered
hand. Unroll the clean pillowcase onto the pillow. Carefully lift the
patients’ head and neck and place the pillow with the clean case on it
under their head.
Cover the patient by putting a clean flat sheet and blanket over the
patient.
Replace the top blankets and finish up. If the bedspread and blanket
were soiled, replace them with a new, clean one. If not, you can put the
original ones back on. Dispose of your gloves and wash your hands.
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16.
Document the procedure once the procedure is done, along with the patient’s
vital signs, response to treatment, and complications if any. This date from
documentation provides information about patient characteristics and care
outcomes.
❖ General guidelines involved in Chest tapping
1.
2.
3.
Prepare the patient by giving a clear explanation of the treatment. This
minimizes distress and uniforms the patient of the procedure.
Obtain consent from the patient. Confirms the patient is willing to take the
treatment.
Auscultate the patient's chest. To ensure no bronchospasm is present prior to
the treatment and to assess which area(s) of the lungs(s) is/are to be treated.
- Auscultation is done by using a tool called a stethoscope and using the
diaphragm of the stethoscope to routinely listen to the patients’ lungs
and heart.
-
4.
5.
6.
7.
Normal breath sound is similar to the sound of air. However, abnormal
breath sounds are rhonchi (a low-pitched breath sound), crackles (a
high-pitched breath sound), wheezing (a high-pitched whistling sound
caused by the narrowing of the bronchial tubes), and stridor (a harsh,
vibratory sound caused by narrowing of the upper airway).
Check the patient's skin integrity over the area of the rib cage to be treated and
take care to avoid performing manual techniques over a portacath and lines and
drains. To ensure skin is intact and no areas of the skin are damaged.
Check the patient's SpO2 level. To ensure desaturation is detected if it occurs
during the treatment.
Position the patient to optimize secretion clearance. This may include modified
postural drainage positions. Tilting or side-lying the patient may use gravity to
assist the mobilization of secretions.
When performing chest percussion a towel may be placed over the area to be
treated. However, avoid too much padding. The technique should not be
performed on bare skin as this may be uncomfortable for the patient, but too
much padding may reduce the effectiveness of the technique.
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8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Perform chest percussion rhythmically with a loose wrist and a cupped hand
over the lung area that is to be treated. This creates an energy wave that is
transmitted to the lung parenchyma to loosen secretions.
A slow single-handed technique or a rapid double-handed technique can be
used. Depending on the patients’ preference. A slow single-handed technique
may be more suitable if the patient is at risk of bronchospasm.
Observe the patient to ensure they are not holding their breath. Breathe holding
may cause oxygen desaturation.
Encourage the patient to perform three to four thoracic expansions during chest
percussion. This can prevent desaturation.
If the patient is prone to desaturation, monitor the patients' oxygen saturations
and respiratory rate throughout the procedure. Supplementary oxygen may be
required during treatment. To ensure the patient remains stable during the
treatment.
To perform shaking and vibrations the hands are placed over the area where
secretions are to be mobilized from and oscillations directed inwards against the
chest in the direction of bucket handle rib movement. Chest compression assists
the mobilization of the secretions from the peripheral to more central airways.
The height of the bed should be adjusted to allow the therapist to use their
body weight to assist with the vibratory/compression action. To augment
expiratory flow and mobilize secretions. The nurse must be aware of their own
posture to protect their back.
Encourage the patient to take a deep inhalation and perform the technique on
their exhalation. To encourage the movement of secretions during expiratory
flow.
Encourage the patient to relax their breathing in between the technique. To
prevent airway closure, desaturation, or bronchospasm.
Use forced expiratory technique or coughing to assist the patient to
expectorate. Allows secretions that have mobilized to central airways to be
expelled.
- The forced expiratory technique is done by having the patient steam up a
mirror they hold in front of them.
The various coughing techniques include cascade, huff, quad coughing, and controlled
coughing:
1. Cascade Cough:
- Ask the client to take a slow deep breath and hold it for 2 seconds, while
contracting expiratory muscles. Tell the client to open the mouth and
perform a series of coughs throughout exhalation, thereby coughing at
lowered lung volumes. This helps for airway clearance and maintains a
patent airway in clients with large volumes of sputum.
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2. Huff Cough:
- In this, the client on exhalation opens the glottis by saying the word
“huff”. The huff cough stimulates a natural cough reflex. This method is
useful for clearing the central airways. Clients, who practice this
regularly, inhale more air and may progress to cascade cough.
3. Quad Cough:
- This is used for clients without abdominal muscle control e.g. clients with
spinal cord injuries. The client or nurse pushes inward and upward on
the abdominal muscles to the diaphragm while the client breathes with
maximal expiratory efforts, causing the cough.
4. Controlled Coughing:
- Ask the client to take two slow, deep breaths, inhaling through the nose
and exhaling through the mouth. Inhale deeply a third time and hold
breath to count of 3. Cough fully for two or three consecutive coughs
without inhaling between coughs. Tell the client to push all air out of the
lungs. The client should be cautioned to cough properly and not just
clear the throat.
Normal lung sounds include:
● Loud, high-pitched bronchial breath sounds over the trachea.
● Medium pitches bronchovesicular sounds over the mainstem bronchi.
● Soft, breezy, low-pitched vesicular breath sounds over most of the peripheral
lung fields.
Abnormal lung sounds include:
● Rales. Small clicking, bubbling, or rattling sounds in the lungs. They are heard
when a person breathes in (inhales). They are believed to occur when air opens
closed air spaces. Rales can be further described as moist, dry, fine, or coarse.
● Rhonchi. Sounds that resemble snoring. They occur when air is blocked or air
flow becomes rough through the large airways.
● Stridor. A wheeze-like sound is heard when a person breathes. Usually, it is due
to a blockage of airflow in the windpipe (trachea) or in the back of the throat.
● Wheezing. High-pitched sounds produced by narrowed airways. Wheezing and
other abnormal sounds can sometimes be heard without a stethoscope.
18.
Document the physiotherapy treatment and its outcome in the patients’ medical
notes. In order to provide a legal record of the treatment and to communicate
its outcome with other health care professionals.
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❖ General guidelines in ORESOL preparation
Children ORESOL preparation:
1. Wash hands with soap and clean water. Handwashing with soap removes germs
from hands.
2. Put the contents of the ORS packet in a clean container. Check the packet for
directions and add the correct amount of clean water. Too little water could
make diarrhea worse.
3. Add water only. Do not add ORS to milk, soup, fruit juice, or soft drinks. Do not
add sugar. This is because the rehydration salts contain the right mix of water
and salts to help the body best.
4. Stir well, and feed it to the child from a clean cup. Do not use a bottle. For
babies, a dropper or syringe (without the needle) can be used to put small
amounts of solution into the mouth.
Child ORS measurement:
-
-
ORESOL should be used when a child has three or more loose stools in a day,
begin to give ORS. In addition, for 10–14 days, give children over 6 months of
age 20 milligrams of zinc per day (tablet or syrup); give children under 6
months of age 10 milligrams per day (tablet or syrup).
A child under the age of 2 years needs at least 1/4 to 1/2 of a large
(250-millilitre) cup of the ORS drink after each watery stool.
A child aged 2 years or older needs at least 1/2 to 1 whole large (250-millilitre)
cup of the ORS drink after each watery stool.
Adult ORESOL preparation:
1.
2.
3.
4.
5.
6.
7.
8.
Wash hands with soap and clean water. Handwashing removes germs from
hands.
Pour all the powder from one sachet of ORS into a clean container that will hold
at least one litre of liquid.
Pour one litre (or the amount indicated in the instructions) of the cleanest water
available into the container and mix it with the powder. ORS water helps restore
the lost salts and glucose of the body.
Give the patient frequent sips from a cup or spoon until he or she is no longer
thirsty.
If the patient vomits, tell the caregiver and wait ten minutes before giving
more.
You can add half a cup of orange juice or mashed banana to the solution to
make it taste better.
If ORS is still needed after 24 hours, make a fresh solution.
If the patient does not improve or signs of severe dehydration appear, take the
patient to a health clinic.
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Adult ORS measurement:
-
For Adults the measurement is 100 ml of ORS every 5 minutes until the
patient stabilizes. The approximate amount of ORS (in milliliters) needed
over 4 hours can also be calculated by multiplying the patient's weight in
kg by 75.
❖ Nursing interventions in the management of fever, cough, and diarrhea
Before tepid sponge bath:
● Observe patients for elevated temperature. Review physician's orders.
● Explain the procedure to the patient.
● Prepare the equipment: Bath basin, Tepid water, Washcloth, Bath thermometer,
Bath blanket, Patient thermometer
● Provide privacy; wash hands.
● Cover the patient with a blanket, remove the gown, and close windows and
doors.
Before chest tapping:
● Instruct the patient to use diaphragmatic breathing.
● Position the patient in prescribed postural drainage positions. Spine should be
straight to promote rib cage expansion.
Before administration of ORESOL:
● Assess vital signs, noting peripheral pulses.
● Monitor blood pressure and invasive hemodynamic parameters.
During tepid sponge bath:
● Test the water temperature. Place washcloths in water and then apply wet
cloths to each axilla and groin.
● Gently sponge an extremity for about 5 minutes. If the patient is in the tub,
gently sponge water over his upper torso, chest, and back.
● Continue sponge bath to other extremities, back, and buttocks for 3 to 5
minutes each. Determine temperature every 15 minutes.
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During chest tapping:
● Percuss or clap with cupped hands or chest wall for 5 minutes over each
segment for 5 minutes for cystic fibrosis and 1-2 minutes for other conditions.
● Avoid clapping over spine, liver, spleen, breast, scapula, clavicle or sternum.
● Instruct the patient to inhale slowly and deeply. Vibrate the chest wall as the
patient exhales slowly through the pursed lips.
● Place one hand on top of the other affected area or place one hand place one
and on each side of the rib cage.
● Tense the muscles of the hands and hands while applying moderate pressure
downward and vibrate arms and hands.
● Relieve pressure on the thorax as the patient inhales.
● Encourage the patient to cough, using abdominal muscles, after three or four
vibrations.
● Allow the patient rest several times.
● Listen with a stethoscope for changes in breath sounds.
During administration of ORESOL:
Strictly monitor intake and output. Observe the physical properties of the urine.
Correctly infuse the right amount of IVF.
After tepid sponge bath:
Change water; reapply freshly moistened washcloths to axilla and groin as
necessary.
● Continue with the sponge bath until body temperature falls slightly above
normal. Discontinue procedure according to SOP.
●
●
●
●
After chest tapping:
● Repeat the percussion and vibration cycle according to the patient’s tolerance
and clinical response: usually 15-30 minutes.
After administration of ORESOL:
● Encourage small, frequent feedings.
● Provide frequent, oral care.
● Administer medications as prescribed.
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CLO#7: Show beginning skills in tepid sponge bath, chest tapping, and
ORESOL preparation
Beginning Skills in:
Tepid sponge bath
Tepid sponging is the application of water to the patient's skin surface to promote
dispersal of body heat when the body temperature is 39.5°C and over. The procedure
is based on the principles of evaporation and conduction.
Procedure:
1. State the purpose and importance of the procedure, bring the equipment to the
bedside.
2. screen the bed and put off the electric fan or aircon.
3. Provide privacy
4. Check the initial temperature and should be checked every 15 minutes intervals.
5. Position the patient comfortably in the bed.
6. Remove the patient gown and place it with a bath blanket.
7. Bring the patient to the edge of the bed.
8. Place the long Mackintosh and draw sheet under the patient.
9. Arrange the articles to the bedside.
10. Wash hands
11. Mix the water with ice cubes.
12. Soak the wash cloths in the ice cold water for some time.
13. Place cold sponge cloths in each axial and groin.
14. Put the face towel under the head, sponge the face and dry with a face towel.
15. Sponge the neck, right arm from the shoulder to the fingertips for 3 minutes.
16. Change sponge cloth when it becomes warm.
17. Sponge the left arm, chest and abdomen for 3 minutes.
18. Change the water if it becomes dirty and check the temperature.
19. Cover the upper half of the body and expose the lower half of the body.
20. Sponge the right and left lower limb for 3 minutes.
21. Then carefully turn the patient to his side and bring the patient to the edge of
bed. Sponge the back with long strokes for 3 minutes.
22. Dry the part with a bath towel and apply spirit on the back.
23. Check the temperature at 20 minutes interval and record it in the TPR chart
24. Remove the sponge clothes from the axilla and groin. Discard it in kidney tray
25. Dry the body with a bath towel.
26. Remove the Mackintosh and draw a sheet.
27. Replace the gown and remove the bath blanket.
28. Observe for any symptoms of chill or any other abnormality.
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29.
30.
31.
32.
33.
If needed, give him hot drinks.
Position the patient comfortably in the bed.
Replace the articles after cleaning.
Wash hands
Record the procedure in the nurse’s record sheet and vital signs in the TPR
sheet.
Chest tapping
The purpose of chest physical therapy, also called chest physiotherapy, or chest
tapping, is to help patients breathe more freely and to get more oxygen into the body.
Chest physical therapy includes postural drainage, chest percussion, chest vibration,
turning, deep breathing exercises, and coughing.
Procedure:
1. Verify/ confirm the order.
2. Confirm the client's ID. Compare the name with the name on the client's ID
bracelet using two client identifiers according to your facility's policy.
3. Provide privacy and explain the procedure to the client.
4. Wash your hands, don gloves, a face shield, and a gown, and follow standard
precautions.
5. Auscultate the client's lungs.
6. Position the client as ordered. In generalized disease, drainage usually begins
with the lower lobes, continues with the middle lobes, and ends with the upper
lobes.In localized disease, drainage begins with the affected lobes and then
proceeds to the other lobes to avoid spreading the disease to uninvolved areas
7. Instruct the client to remain in each position for 10 to 15 minutes. During this
time, perform percussion and vibration, as ordered.
8. After postural drainage, percussion, or vibration, instruct the client to cough to
remove loosened secretions. First, tell the client to inhale deeply through the
nose and then exhale in three short huffs. Then, have the client inhale deeply
again and cough through a slightly open mouth. Three consecutive coughs are
highly effective. An effective cough sounds deep, low, and hollow; an ineffective
one sounds high pitched.
9. Have the client perform coughing exercises for about 1 minute and then rest for
2 minutes. Gradually progress to a 10-minute exercise period four times daily.
10. If the client's cough is ineffective, suction the client.
11. Monitor the client's response to the treatment. Be alert for significant color
changes, particularly if the client becomes dusky.
12. Dispose of secretions appropriately.
13. Provide oral hygiene.
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14. Auscultate the client's lungs.
15. Record the date and time of chest PT, as well as which chest segments were
percussed or vibrated, the color, quantity, odor, and viscosity of any secretions
generated, as well as the presence of any blood, any problems and nursing
interventions, and the client's tolerance of therapy.
ORESOL preparation
Drinking ORESOL helps maintain electrolyte balance in the Human Body. It helps the
body absorb H2O, which is why it is used to replace fluids and minerals lost due to
diarrhea or vomiting.
Procedure:
● Made at home
1. Do medical hand washing.
2. Measure the correct proportion of boiled water, and salt and sugar.
2.1 1 glass mixture: - 1 teaspoon sugar - a pinch of salt - 240 mL of boiled
water
2.2 1 Liter mixture: - 8 teaspoon sugar - 1 teaspoon salt - 1000 mL/ 1 liter of
boiled water
3. Prepare the solution in a clean container.
4. Stir the mixture until all the solutes dissolve.
● Pre-packed formula
A prepacked formula of ORESOL is a powder that usually consists of a mixture of
glucose sodium chloride, potassium chloride, and sodium citrate that can be dissolved
in the requisite amount of water.
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