Introduction to Clinical Skills in Patient Care
Unit One
Infection and Asepsis
Asepsis
 Asepsis: is the absence of pathogenic microorganisms.

Aseptic technique: is the procedure that keeps a patient as free from
microorganisms.

Types of aseptic technique:
1. Medical (clean technique): includes process used to reduce number and
prevent the spread of microorganisms e.g. hand washing and isolation.
2. Surgical: includes process used to eliminate pathogen and spores completely.
 Types of Asepsis (aseptic technique):
1. Medical
2. Surgical.
1. Medical Asepsis:
 Hand washing (normal or usual).
 Precautions: Use of barriers: mask, gown, caps and shoes cover, gloves
 Isolation: is the interrupting of the transmission of infectious organisms.
 Cleaning and disinfectant.
 Precaution: Precaution to prevent transmission of microorganisms.
It include
1. Standard precaution:
A. Wash hands after touching blood, body fluids, secretions,
excretions, mucous membranes, no intact skin, and contaminated
items.
B. Wear gloves when touching blood, body fluids, secretions,
excretions, mucous membranes, non intact skin, and contaminated
items. Remove gloves promptly after use and wash hands.
C. Wear a mask and eye protection when performing procedures or
patient care activities likely to generate spray or splashes.
D. Wear a gown during procedures or patient care activities that may
generate spray or splashes of blood or other body fluids.
1
E. Disinfect or sterilize all reusable equipment between patients.
Handle contaminated equipment in a manner that prevents
contamination of skin, clothing, or the environment.
F. Disinfect environmental surfaces, beds, and bedside equipment.
G. Prevent injuries by safe handling of sharps.
H. Use mouthpieces, resuscitation bags, or other ventilation devices as
an alternative to mouth-to-mouth resuscitation.
2. Universal precaution:
A. It is about the transmission of blood borne diseases (e.g., AIDS,
hepatitis B virus [HBV]).
B. Health- care workers use gloves, gowns, masks, and protective eye
wear when exposure to blood or body fluids was likely.
C. All patients should be considered potentially infected.
D. Blood, semen, vaginal secretions, and possibly breast milk could
transmit an infection. Although the risk was unknown, universal
precautions also applied to cerebrospinal, synovial, pleural,
peritoneal, pericardial, and amniotic fluids.
E. Universal precautions did not include feces, nasal secretions,
sputum, sweat, tears, urine, and vomitus, unless they contained
visible blood.
F. Needles were not being recapped and disposed in resistance
container.
3. Body substance isolation
A. Body substance precautions (or body substance isolation) are an extension of
universal precautions.
B. Consider all body substances potentially infective, regardless of a person's
diagnosis, and advocate consistent use of barriers whenever healthcare
personnel have contact with moist body substances, mucous membranes, and
nonintact skin.
2
C. Disposable gloves and needle disposal containers are placed in every room.
D. Each patient interaction requires good hand washing technique before and
after care.
4. Airborne precaution:
Examples of illness required airborne precautions: Measles, Chickenpox,
and Tuberculosis.
A. Use private room with:
 Monitored negative air pressure.
 6-12 air changes per hour.
 Discharge of air outdoors or HEPA filtration before air is recirculated.
Keep room door closed and patient in room.
B. Ensure respiratory protection:
 Wear a respirator mask for known or suspected cases of tuberculosis.
 Susceptible individuals should not enter the room of patients with known
or suspected cases of measles (rubeola) or varicella (chickenpox) if
immune caregivers are available.
 If susceptible individuals must enter the room, a mask is required.
C. Limit the movement and transportation of patients outside the room to
essential purposes only. During transport, minimize the spread of droplet
nuclei by placing a surgical mask on the patient if possible.
5.
Droplet precaution:
A. Place the patient in a private room. If a private room is not available, put him
with patients who have an active infection with the same microorganism but
who have no other infection. Maintain spatial separation of at least 1 meter
from other patients and visitors is not available. Room door may remain
open. Special ventilation is not required.
B. Mask is required when working within 1 meter of patient or when entering
the room (according to hospital's policy).
C. Limit the movement and transportation of patients outside the room to
essential purposes only. During transport, minimize the spread of droplets by
placing a surgical mask on the patient if possible.
3
D. Examples of illness required droplet precautions:
a. Invasive H. influenzae type b disease (meningitis, pneumonia,
epiglottitis, and sepsis).
b. Invasive Neisseria meningitis disease (meningitis, pneumonia)
c. Invasive multidrug-resistant Streptococcus pneumonia disease
(meningitis, pneumonia, sinusitis, and otitis media)
d. Other bacterial: Diphtheria (pharyngeal), Mycoplasma pneumonia.
e. Serious viral infections spread by droplet transmission, including:
Adenovirus, Influenza, Mumps, and Rubella.
6. Contact precaution:
Use in addition to Standard Precautions.
A. Place the patient in a private room or collect patients who have active
infection with the same microorganism but who have no other infection.
B. Wear gloves when entering the room. Change gloves after contact with
infective material. Remove gloves before leaving the patient's room.
C. Wash hands immediately with antimicrobial agent before leaving the
patient's room. After removing gloves and washing hands, ensure that hands
do not touch possibly contaminated environmental surfaces or items in the
patient's room to avoid transferring microorganisms to other patients or
environments.
D. Wear a gown if you anticipate that your clothes will have substantial contact
with the patient, environmental surfaces, or items in the patient's room or if
the patient has any of the following:
 Colostomy
 Diarrhea
 lleostomy
 Incontinence
 Wound drainage not contained by a dressing
E. Remove gown before leaving the patient's environment.
F. Limit the movement and transportation of patients outside the room to
essential purposes only. During transport, ensure that all precautions are
maintained at all times.
G. When possible, dedicate the use of noncritical patient care equipment for
each patient.
 Example of illness required contact precaution:
4
o
o
o
o
Enteric infections with a low infectious dose or prolonged
environmental survival, including: Clostridium.
For diapered or incontinent patients: Escherichia coli,
Shigella infections, hepatitis A.
Respiratory: parainfluenza virus infections.
Skin infections: Herpes simplex virus, wound infections, and
Scabies.
 Isolation (Private Room):
o Isolation: is a technique used to prevent or the spread of infection. It is
the interrupting of the transmission of infectious organisms. Isolation
Systems is costly (equipment, personnel, and time).
o Purpose of Isolation:
a. To protect a high-risk person from exposure to pathogens (defense
mechanism compromised; who gets chemotherapy, radiation
therapy, immunosuppressive medication, and burn cases).
b. Prevent transmission of pathogens from infected person to another.
o
Protective isolation: in addition to the precautions the following
points must be followed:
a. Hand washing for all (patient, family, health workers). Visitors are
restricted.
b. No fresh fruits or vegetables are allowed (caned and cocked food).
o Notes in isolation:
1. Patients with same infection placed in the same.
2. Negative-airflow rooms: indicated for TB and organisms
transmitted by the airborne route.
3. Risk groups include: children younger than 5 y, patients with
altered mental status, and patient with wounds.
4. If transport to other departments is necessary (don’t try to transport
patient when it's unnecessary):
a. The gown and dressings should be changed before leaving the
room and the patient should wear appropriate barriers (mask
or gown).
b. The transporters should be immunized to the disease.
c. Be sure to notify the department where the patient is being
transported so staff is aware of the patient status and can take
appropriate precautions.
5
o Prepare all equipment needed during working with patient and replace
the used one immediately. All need equipment (actual or potential)
must be available in patient room. After finishing isolation must be
cleaned and sterilized by appropriate way according to the type of
equipment.
o Psychological effect of isolation: Patient spends more time alone
(separated), the hand and faces of worker are covered, and patients
feeling that they are dirty & untouchable. Can be prevented by identify
of the purpose of isolation.
o Serve isolation food tray: Provide of food for patient in isolation room
is not different form non-isolated patient except:
a. All the used instruments used are disposable or sterile.
b. Wear all protective devices (protection for nurse and patient)
while you providing and helping patient in eating.
2. Surgical Asepsis:
includes process used to eliminate pathogen and spores.
o Techniques used in Surgical Asepsis:
1. Disinfectant and Antisepsis
2. Sterilization
o Surgical Asepsis
1. Prevent the organism from entering the body.
2. Used when skin broken and membranes are perforated (all things that
contacts with the body must be free of microorganisms).
3. Used in many satiations: dressing changes, catheterization, and in operations
(sterilization of all materials that come in contact with the wound).
o Principles of surgical asepsis.
1. Moisture causes contamination.
 Handle liquids carefully near sterile fields.
 Place wet objects on sterile, water-resistant surfaces, such as sterile
basins.
2. Never think that an object is sterile.
 Check to see that it is labeled as sterile.
 Check the integrity of the packaging and expiration date.
3. Always face the sterile field.
4. Sterile articles touch only sterile articles or surfaces (if to maintain
sterility).
5.
Sterile equipment or areas must be kept above the waist and on top of the
sterile field.
6. Prevent air currents around the sterile area.
 Close doors.
6

Unfold drapes or wrappers slowly.
 Do not sneeze, cough, or talk excessively over the sterile field.
 Do not reach across sterile fields.
7. Open, unused sterile articles are no longer sterile after the procedure.
8. A person who is considered sterile who becomes contaminated must
reestablish sterility.
9. Surgical technique is a team effort.
Sterilization
o Sterilization: process by which all forms of living microorganism are completely
destroyed including spores and viruses.
o Sterilization done in the central unites in the hospital or surgical areas called
central sterilization unite.
o Sterilization method depends on:
1. Type of materials.
2. Type of microorganisms.
3. Degree of contamination: increased contamination time → need more time.
o Methods of sterilization:
1. Steam under pressure (autoclaving): most commonly used type.
 Time: for 15-20 minutes.
 Temperature: mainly 121 C (250 F) & pressure 15-17 pounds.
 At the completion: pressure reduced to zero and allows supplies to dry.
2. Dry heat sterilization (oven): circulation of hot air:
 Can penetrate many different materials.
 Time: 1-6 hours (depend on type of material, packaging & load of oven).
3. Chemicals e.g. Ethylene oxide
4. Irradiation: infrared.
Disinfectant:
1. Disinfectant: eliminates many or all pathogenic organisms except for bacteria
spores by using of chemical liquids. Used for nonliving objects e.g. instruments.
2. Instruments may be:
1. Critical: contaminated with microorganisms (surgical instrument).
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2. Semicritical: come in contact with mucous membrane or nonintact skin
(anesthesia instrument and bronchoscope).
3. Noncritical: contact with unbroken skin (BP cuff and ECG electrodes).
4. Environmental surfaces: medical equipment surfaces (ventilators and x-ray
machines) and housekeeping surfaces (floors, table and curtain).
o Factors that affect the disinfectant:
1. Time: glutaraldehyde 20 min high level. For 10-12 hours become sterilization.
2. Type of instrument (smooth, curved, pores).
3. Microorganism's type.
4. Presence of contaminated materials on the instrument (blood or pus or mucus).
Some of the disinfectant becomes inactive with the presence of these
materials. So that it must be cleaned before using disinfectant.
o Disinfectant for lifeless object may be used for living object when it is diluted.
Antiseptics:
o Antiseptics (disinfectant for living object e.g. skin) are preparations used to
inhibit or destroy microorganisms (not all living microorganisms; bacterial
spores may not be killed). Example is alcohol, iodine.
o Used for hand washing, surgical wash, skin preparations for surgery or insertion
of devices.
o You must follow the instruction for use.
8
Introduction to Clinical Skills in Patient Care
Unit Two
Health Assessment: Vital Signs

Components Of A Vital Signs Assessment:
1.
2.
3.
4.
Body Temperature (T)
Pulse (P)
Respirations (R)
Blood Pressure (BP)

Important points about vital signs:
o Pain may be described as the fifth vital sign.
o These signs enable nurses to monitor the functions of the body.
o The signs reflect changes that otherwise might not be observed.

Factors Which Influence The Recording Of Vital Signs Include:
1.
2.
3.
4.

Environmental Temperature
Exercise
Illness / Disease
Emotion e.g., anxiety
Alterations
Indicate:
In Vital Signs From A Client's "Normal Range" May
1. Alteration in physiological status.
2. The need for medical monitoring &/or immediate medical
intervention.

When Should A Nurse Take Vital Signs ?
1. On admission to hospital.
2. According to physician’s instructions.
3. Before, during and following surgery or a diagnostic procedure (as
applicable).
4. Before, during and following the administration of medications (as
applicable).
5. According to changes in a client’s condition e.g. pain, loss of
consciousness, abnormally high or low vital signs.
6. When a client states they feel a change in their condition.
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NORMAL VITAL SIGN RANGES
Age
Pulse
(beats
per
minute)
Blood Pressure
Respirations
Temperature
(mm Hg)
(breaths per
(oral)
Systolic Diastolic
minute)
Adult
60 – 100
12 – 20
36.5-37.5
(80)
(16)
(37oC)
90 – 140
60 – 90
Body Temperature:
o
Body temperature is the balance between the heat produced by the body
and the heat lost from the body.
o
There are two kinds of body temperature: core temperature and surface
temperature. Core temperature is the temperature of the deep tissues of
the body (e.g. abdominal cavity and pelvic cavity).
o
The normal core body temperature is not an exact point on a scale but a
range of temperatures.
o
The surface temperature is the temperature of the skin, the subcutaneous
tissue and fat. Surface temperature, by contrast, rises and falls in response
to the environment.
Pulse:

The pulse is the palpable bounding of blood flow noted at various points on
the body.

It is an indicator of circulatory status; therefore, the client as a whole should be
assessed e.g., color of lips, nail beds and skin.

When a pulse wave reaches a peripheral artery, its can be felt by palpating the
artery lightly against underlying bone or muscle.

The number of pulsing sensations occurring in 1 minute is the pulse rate.

The volume of the blood pumped by the heart during 1 minute is the cardiac
output (in an adult the heart normally pumps 500 mL of blood per minute).
10

Assessment Of Pulse:
o Any artery can be assessed by pulse rate, but the radial and carotid
arteries are easily palpated peripheral pulse sites.
o A peripheral pulse is a pulse located in the periphery of the body (e.g.
in the foot, hand, or neck).
o The radial and apical locations are the most common sites for pulse
rate assessment.
o When a client takes medication that affects the heart rate, the apical
pulse may provide a more accurate assessment of heart function.
o The brachial or apical pulse is the best site for assessing an infant’s
or young child’s pulse because other peripheral pulses are deep and
difficult to palpate accurately.

Character Of The Pulse:
o Assessment of the radial pulse includes measurement of the rate,
rhythm, strength and equality.
o When auscultating an apical pulse, the nurse assesses rate and rhythm
only.

Rate:
o Two common abnormalities in pulse rate are:
 Tachycardia: pulse rate more than 100 b.p.m. in an adult.
 Bradycardia: pulse rate less than 60 b.p.m. in an adult.

Apical Rate:
o The nurse assesses the apical rate by listening for heart sounds.
o The nurse tries to identify the first and second heart sounds (S1 and S2).
o Using the diaphragm or bell of the stethoscope, the nurse counts the
number of heart sounds occurring in 1 minute.

Rhythm:
o Normally a regular interval occurs between each pulse or heartbeat.
o An interval interrupted by an early or late beat or a missed beat
indicates an abnormal rhythm or dysrhythmia.
11

Pulse Assessment Sites:
1. Temporal, where the
temporal artery passes
over the temporal bone of
the head.
2. Carotid, at the side of the
neck below the lobe of the
ear, where the carotid
artery runs between the
trachea
and
the
sternocleidomastoid
muscle.
3. Apical, at the apex of the
heart. In an adult this is
located in the left chest,
about 8 cm (3 in) left of
the sternum (breastbone)
at the fifth intercostal
space.
4. Brachial, at the inner
aspect of the biceps
muscle of the arm or
medially in the antecubital
space. where the radial artery runs along the radial bone, on the thumb side
5. Radial,
of the inner aspect of the wrist.
6.
Femoral, where the femoral artery passes alongside the inguinal ligament.
7. Popliteal, where the popliteal artery passes behind the knee.
8. Posterior tibial, on the medial surface of the ankle where the posterior tibial
artery passes behind the medial malleolus.
9.
Pedal (dorsalis pedis), where the dorsalis pedis artery passes over the bones
of the foot. This artery can be palpated by feeling the dorsum of the foot on
an imaginary line from the middle of the ankle to the space between the big
toe and second toe.
12
Respiration:


Respiration is the act of breathing. It includes the intake of oxygen and the
output of carbon dioxide.
o Inhalation or inspiration intake of air into the lungs.
o Exhalation or expiration breathing out or the movement of
gases from the lungs to the atmosphere
Assessment Of Respirations:
o Accurate measurement requires observation and palpation of chest wall
movement.
o A skillful nurse does not let a client know that respirations are being
assessed - a client aware of the nurse’s intentions may consciously alter
the rate and depth of breathing.
o Assessment can best be done immediately after measuring pulse rate,
with the nurse’s hand still on the client’s wrist as it rests over the chest
or abdomen.
o The objective measurements of an assessment of respiratory status
include the rate and depth of breathing and the rhythm of ventilatory
movements and the use of accessory muscles when respiratory distress
is evident.

Respiratory Rate:
o The nurse should observe inspiration and expiration for one minute
when counting the respiratory rate.
Blood Pressure:

Blood pressure is the force that blood exerts against the walls of the blood
vessels as it is pumped around the body by the force of ventricular
contractions.

Blood pressure varies within the vascular system; for example, arterial
systolic pressure (120 mmHg) is higher than capillary pressure (25
mmHg).

Blood pressure can be measured indirectly (non invasive) or directly
(invasive).

In healthy adults, client positioning makes little difference to their recording of
blood pressure measurements; however, in some medical conditions (e.g.,
13
postural hypotension) there is a significant difference between lying, sitting
and/or standing blood pressure readings.

Because blood moves in waves, there are two blood pressure measures:
1. The systolic pressure, the pressure of the blood as a result of
contraction of the ventricles (i.e. the pressure of the height of the
blood wave).
2. The diastolic pressure, the pressure when the ventricles are at rest.
o Diastolic pressure, then, is the lower pressure, present at all times
within the arteries.
o The difference between the diastolic and systolic pressures is called the
pulse pressure.

Assessing Blood Pressure:
o Blood pressure may be measured directly with a catheter placed into an
artery (invasive).
o Blood pressure is usually measured by indirect methods, using an
inflatable cuff to temporarily occlude arterial blood flow through one
of the limbs (non invasive).
o As the cuff is deflated and flow returns, the blood pressure can be
determined by palpation,(feeling) auscultation (listening) or
oscillations.

Possible Sites For Recording:
o Blood pressure is usually assessed in the client’s arm using the brachial
artery and a standard stethoscope.
o Assessing the blood pressure on a client’s thigh using the popliteal artery is
usually indicated in these situations:
 The blood pressure cannot be measured on either arm (e.g. because
of burns, trauma, or bilateral mastectomy).
 The blood pressure in one thigh is to be compared with the blood
pressure in the other thigh.
 The blood pressure cuff is too large for the upper extremities.
o Blood pressure is not measured on a client’s arm or thigh in the following
situations:
14
 The client has had breast or axilla (or hip) surgery on that side.
 The client has an intravenous infusion or a blood transfusion in that
limb.
 The client has an arteriovenous fistula (e.g. for renal dialysis) in
that limb.

Proper Positioning:
o Blood pressure should be measured at heart level (elevating the arm
above heart level results in a falsely low measurement whilst
positioning the arm below heart level results in a falsely high reading;
therefore, the client should be flat).
Recording Vital Signs:
15
Introduction to Clinical Skills in Patient Care
Unit Three
Medication Administration
 Medications: is a substance administered for the diagnosis, care, treatment,
mitigation (relief), or prevention of disease.
 In the health care context, the words medication and drug are generally used
interchangeably.

Principles of Medication Administration:

Medication given as physician described (ordered).

Type of orders includes:
1. Standing order: carried out regularly until the another order that
cancelled (stopped) the medication.
2. As needed "P.R.N" or "S.O.S": given when patient needs the
medication.
3. Single dose: one dose at the time specified by doctor e.g.
preoperative medication.
4. Stat order: one dose carried immediately.
5. Telephone, verbal, and fax order.

Parts of the medication order:
1. Patient's name.
2. Date and time of order.
3. Name of drug.
4. Dose and route.
5. Frequency.
6. Signature.

To be safe when you work with medication:
1. Check the label of the medication container three times:.
o When reach the container.
o Before opening of the medication.
o Before drawing the medication.
2. Ten rights:
1. Right Patient
2. Right Medication
3. Right Dosage
4. Right Route
16
5. Right Time
6. Right Documentation
7. Right Client Education
8. Right to Refuse
9. Right Assessment
10. Right Evaluation
3. Maintain safe environment.
4. Caring for controlled substances (narcotics): this type of
medication is used with a valid prescription and in a limited
amount. Because narcotics easily causing the addiction.
5. Document of medication administration.
Routes of administration:
1. Oral: is the most common, least expensive and most convenient route for most
clients.
2. Sublingual: A drug is placed under the tongue, where it
dissolves.
3. Buccal: means “pertaining to the cheek.” In buccal
administration, a medication (e.g. tablet) is held in the
mouth against the mucous membranes of the cheek until
the drug dissolves.
Sublingual
4. Parenteral: is defined as other than through the
alimentary or respiratory tract; that is by needle.
Common routes for parenteral administration inclu,de:
a. Subcutaneous – into the subcutaneous tissue, just
below the skin.
b. Intramuscular – into a muscle.
c. Intradermal – under the epidermis (into the
dermis).
d. Intravenous – into a vein.
Buccal
5. Topical: are those applied to a circumscribed surface area of the body. They
affect only the area to which they applied. They include:
a. Dermatological preparations-applied to the skin.
b. Instillations and irrigations-applied into body cavities or orifices, such
as urinary bladder, eyes, ears, nose, or rectum.
c. Inhalations-administered into the respiratory tract by a nebulizer or
with breathing.
17
Types of medication orders:
1. Stat order: the medication is to be given immediately and only once. For
example:
Demerol 100ng IM stat.
2. Single order: one-time order, the medication to be given once at a specified
time. For example:
Atropine 1mg IM before surgery.
3. Standing order: a regular order, may or may not have a termination date.
When there is no termination date, another order must be written to cancel it.
For example:
Ampicillin 1gm IV q4h or Ampicillin 1gm q6h × 5days.
4. PRN order: as needed order, permits the nurse to give a medication when, in
the nurse's judgment, the client require it. For example:
Paracetamol 2tab prn (PRN)
Common abbreviations used in medication orders:
Abbreviation
Explanation
Abbreviation
Explanation

Bid
Twice a day

Q
Every

Cap
Capsule

Qam
Every morning

comp
Compound

qh (q1h)
Every hour

g, or gm
Gram

q2h
Every two hours

h
An hour

q3h
Every three hours

hs
Hour of sleep

q4h
Every four hours

ID
Intradermal

q6h
Every six hours

IM
Intramuscular

Qid
Four times a day

IV
Intravenous

Qod
Every other day

Kg, kg
Kilogram

SC
Subcutaneous

L, l
Liter

SOS
It it is needed

Mcg, or µg
Microgram

Stat
At once

Mg, or mgm
Milligram

Sup, sup
Suppository

No.
Number

Susp
Suspension

Po
By mouth

Tab
Tablet

Prn
When needed

Tid
Three times a day
18
Converting weights:
 Only three units of weight are used for drug dosage:
1. The gram (g)
2. The milligram (mg)
3. The microgram (µg or mcg)
***1g = 1000mg
***1mg = 1000µg
 Exercise:
1. Convert 500mg into grams?
2. Convert 0.006g into mg?
3. Convert 2500µg into mg?
4. Convert 0.5mg into micrograms?
5. Convert 0.1gm into microgram?
6. Convert 250,000µg into grams?
Calculating Dosages:
 Several formulas can be used to calculate drug dosages. One formula uses
ratio:
Dose on hand
=
desired dose
.
Quantity on hand
quantity desired (x)
For example: erythromycin 500mg is ordered. It is supplied in a liquid
form containing 250mg in 5ml. To calculate the dosage, the nurse uses the
formula:
Dose on hand (250mg) =
desired dose (500mg)
.
Quantity on hand (5ml)
quantity desired (x)
Then, the nurse cross-multiply:
250x = 5ml × 500mg
x = 5ml × 500mg
250 mg
x = 10ml.
Therefore, the dose ordered is 10ml.
 The previous formula can be written in another way:
Amount to be administered (x) = desired dose .× quantity on hand
Dose on hand
For example: heparin is often distributed in large vials and prepared
dilutions of 10,000 units per 1ml. If the order calls for 5000 units, the nurse
can calculate using the formula above:
x = 5000 units × 1ml
10,000
x = 1 ml
2
Therefore, the nurse injects 0.5ml heparin for a 5000-unit dose.
19
 Exercise:
1. An ampoule of digoxin contains 0.5mg in 2ml. An infant need
50microgram. Calculate the amount to be drawn?
2. A client needs 50mg hydrocortisone IV. You have vial contains
100mg/2ml. Calculate the amount to be given?
Parenteral medications:
 To administer parenteral medications, nurses use injectable equipment which
include:
1. Syringes: syringes have three parts, the tip, the barrel and the plunger.
2. Needles: needle has three parts, bevel,
shaft and hub.
3. Vials and Ampoules:
 A vial is a small glass
bottle with a sealed
rubber cap.
 Ampoule is a glass
container
usually
designed to hold a
single dose of a drug.
Ampoule file is used when ampoule is not
scored.
Administering an Intradermal Injection:
 Is the administration of a drug into the dermal layer of the skin just beneath the
epidermis.
 This type of injection is indicated for:
1. Allergy test.
2. Tuberculin test.
3. Some vaccinations.
Sites:
 Common sites for intradermal injections are:
1. The inner lower arms.
2. The upper chest.
3. The back beneath the scapula.
 Usually only a small amount of liquid is used, for example, 0.1ml.
 Avoid using sites that are tender, inflamed, swollen, or those that have lesions.
20
Administering a Subcutaneous Injection:
 Many
kinds
of
drugs
are
administered
subcutaneously, but the most common are:
1. Insulin.
2. Heparin.
3. Vaccines.
 Common sites for subcutaneous administration are:
1. Outer aspect of upper arm.
2. Anterior thigh.
3. Abdomen.
4. Scapular area.
 Only small doses (0.5 to 1 ml) of medication are
usually injected via the subcutaneous route. Generally
a 2-ml syringe is used for most SC injections.
Administering an Intramuscular (IM ) Injection:
 Injections into muscle tissue are absorbed more quickly than subcutaneous
injection because of greater blood supply to muscles.
 Muscles can take a larger volume of fluid without discomfort than
subcutaneous tissue can.
 An adult with well-developed muscles can usually safely tolerate up to
4ml of medication in the gluteus medius and gluteus maximus muscles.
 A volume of 1-2 ml is usually recommended for adults with less
developed muscles.
 In the deltoid muscle, volumes of 0.5 to 1ml are recommended.
 Several sites can be used for intramuscular injections, theses sites include:
1. Ventrogluteal site:
 The ventrogluteal site is in the gluteus medius muscle.
 This site is suitable for children over 7 months
and adults.
 To establish the exact site, the nurse places the
heel of the hand on the client's greater
trochanter, with the fingers pointing toward
the client's head. The right hand is used for the
left hip, and the left hand is used for the right
hip. With the index finger on the client's
anterior superior iliac spine, the nurse
stretches the middle finger dorsally (toward the buttocks), palpating the
crest of the ileum and the pressing below it. The triangle formed by the
index finger, the third finger, and the crest of the ileum is the injection
site.
21
2. Vastus lateralis site:
 The vastus lateralis
muscle is usually
thick
and
well
developed in both
adults and children.
 It is recommended as
the site of choice for
infants 7 months and younger.
 It is situated on the anterior lateral aspect of the
infant's thigh. The middle third of the muscle is suggested as the site.
3. Dorsogluteal site:
 The dorspgluteal site is composed of the thick gluteal muscles of the
buttocks.
 This site can be used for adults and for children with well-developed
gluteal muscles. Because these muscles are developed by walking, this
site should not be used for children under
3 years unless the child has been walking
for at least 1 year.
 The nurse palpates the posterior superior
iliac spine, then draws an imaginary line
to the greater trochanter of the femur. The
injection site is lateral and superior to this
line.
4. Deltoid site:
 The deltoid muscle is found on the lateral aspect
of the upper arm.
 It is not used often for intramuscular injections
because it is relatively small muscle and is very
close to the radial nerve and radial artery.
 No more than 1ml can be administered.
 This site is recommended for the administration
of hepatitis B vaccine in adults.
 The upper landmark for the deltoid site is located
by the nurse placing four fingers across the deltoid
muscle with the first finger on the acromion
process. The top of the axilla is the line that marks
the lower border landmark.
 The use of a pinch-grasp technique can reduce the
discomfort of an IM injection into the deltoid
muscle.
5. Rectus femoris site:
 This site is used occasionally for IM injections.
 It is situated on the anterior aspect of the thigh.
22
Adding Medications to Intravenous Fluid Containers
Purposes:
1. To provide and maintain a constant level of a medication in the blood.
2. To administer well-diluted medications as a continuous and slow rate.
Administering Intravenous (IV) Injection through Cannula (push):
Purposes:
1. To achieve immediate and maximum effects of a medication.
Administering Intravenous (IV) Injection through Direct method.

Drug forms, Packaging, and Labelling:
o Drug forms and Packaging:
 Each drug has special way for storage.
 Some type of medication need refrigerator for example
insulin and immunization.
 Others medication may be stored at room temperature.
 The following table provides most common drug forms.
o Drug Labelling:
 Drug label contains:
1. Drug name (trade or generic name) and dose.
2. Route for administration.
3. Production and expiry date.
 When you need to keep amount of medication in a container or
syringe. You must write the following:
1.Medication name.
2.Dose (how much unit/amount e.g. 500 mg in 5 cc)
3.Type of solvent.
4.Date and time of mixing or dissolving the drug.
5.Name and signature.
23
Introduction to Clinical Skills in Patient Care
Unit Four
Intravenous (IV) Therapy and Blood Administration
 Intravenous (IV) fluid therapy is essential when clients are unable to take food and
fluids orally.
 IV fluid therapy is usually ordered by the physician. The nurse is responsible for
administering and maintaining the therapy.
 Venipuncture Sites:
 For adults, veins in the hand and arm are
commonly used. The metacarpal, basilica, and
cephalic veins are commonly used.
 For infants, veins in the scalp and dorsal foot
veins are often used.
 When long-term IV therapy or parenteral nutrition
is anticipated or the client is receiving IV medication that
are
damaging
vessels
(e.g. chemotherapy), a central nervous catheter may be
used.
 Central venous catheters usually are inserted into the
subclavian or jugular vein, with the distal tip of the
catheter resting in the superior vena cava just above the
right atrium.
Subclavian vein insertion
Left jugular insertion
 Intravenous Equipments:
1. Solution containers:
 Solution containers are available in various sizes
(50, 100, 250, 500, or 1000ml).
 Most solutions are currently dispensed in plastic
bags. Glass containers require an air vent so that air
can enter the bottle and replace the fluid that enters
the client's vein.
2. Infusion sets:
 Infusion sets usually include:
i. Insertion spike.
ii. A drip chamber.
iii. A roller valve.
iv. Tubing with secondary ports.
24
v. A protective cap over the needle adapter.
 A special infusion set may be required if the IV flow rate will be
regulated by an infusion pump.
3. Catheters and Needles (cannulas):
 The plastic catheter fits over a needle used to pierce the skin and
vein wall. Once inserted into the vein, the needle is withdrawn and
discarded, leaving the catheter in place.
 Butterfly needles with plastic flaps attached to the shaft are
sometimes used.
4. IV poles (stands):
 IV poles are used to hang the solution container.
 Some poles are attached to hospital beds; others stand on the floor
or hang from the ceiling.
o Duration of IV canunulation:
 Not longer than 6 days for children (risk for infection)
 2- to 3-day in adults (risk for developing phlebitis).
o Type of solutions:
a. Hypotonic solutions:
1. 0.33% NaCI,
2. 0.45% NaCI.
b. Isotonic solutions:
1. 5 % dextrose in water (DW),
2. 0.9% NaCI (normal saline; NS),
3. Ringer's Lactated solution (RL)
c. Hypertonic solutions:
1. 5% dextrose in 0.45% NaCI,
2. 10% DW,
3. 5% dextrose in 0.9% NaCI.
Regulating and monitoring intravenous infusions:
 Unless an infusion control device is
used, the nurse manually regulates the
drops per minute of flow using the
roller clamp.
 The number of drops delivered per
millilitre of solution varies with
25
different brands and types of infusion sets. This rate is called the drip factor
or drop factor. Macrodrops commonly have drop factors of 10, 12, 15, or
20drops/ml; the drop factor for microdrip is always 60drops/ml.
 To calculate flow rates, the nurse must know the volume of fluid to be infused
in a specific time, for example, drops per minute.
 Drops per minute are calculated by the following formula:
Drops per minute = total infusion volume × drop factor
total time of infusion in minutes

If the requirements are 1000ml in 8 hours and the drip factor is 20
drops/ml, the drops per minute should be:
Drop per minute = 1000ml × 20 = 41 drops/minute
8 × 60 (480)
 Hourly rates of infusion can be calculated by dividing the total infusion
volume by the total infusion time in hours. For example, if 3000 ml is infused
in 24 hours, the number of milliliters per hour is:
3000ml = 125 ml/h
24 h
o IV Adverse Reaction: (Complications of Intravenous Therapy):
1. Infiltration:
o Occurs when IV fluids enter the subcutaneous space around the
venipuncture site.
o
o
S&S:
1.
2.
3.
4.
Swelling (from ↑tissue fluid).
Pallor (caused by ↓ circulation).
Decreased rate or stopped flowing.
Pain.
Intervention:
1. Discontinue IV therapy.
2. Needle is reinserted into another extremity.
3. Raise the extremity to promote venous drainage.
4. Warm compresses for 20 minutes (promotes venous
return, increases circulation, and reduces pain and
edema).
2. Phlebitis:
o
is an inflammation of the vein.
o S&S:
1. Pain.
26
2. Increased skin temperature over the vein.
3. Redness along the path of the vein.
o
Intervention:
1. Discontinue IV line .
2. Insert a new line in another vein.
3. Warm moist heat on the site of phlebitis.
4. Place a piece of tape or pre-printed label with the date
and time of tubing change.
o
Risk factors for phlebitis:
1. Type of catheter material.
2. Drugs given intravenously (e.g., antibiotics).
3. The anatomical site of the catheter.
o
Complication:
1. Blood clots formation (thrombophlebitis) that may lead
to emboli.
o
Phlebitis is prevented by routine removal and rotation of IV
sites (every 48 to 72 hours).
3. Fluid volume excess:
o Cause: too-rapid administration of IV solutions.
o S&S:
1. Shortness of breath.
2. Crackles in the lungs.
3. Tachycardia.
o
Intervention:
1. Slow the rate of infusion.
2. Notify the physician.
3. Raise the head of the bed.
4. Monitor vital signs.
4. Bleeding:
o common in patients who have received heparin or who have a
bleeding disorder (e.g., leukemia).
o
Cause:
1. Disconnection of the infusion.
2. Through the catheter needle.
27
o
Intervention:
1. Reconnect the infusion.
2. Apply a pressure dressing over the site to control the
bleeding.
3. Assess the amount of blood and haemoglobin level if
the amount is large.
Blood Transfusion:

Blood Components:
o Blood composed of:
a. Blood Cells:
1. Red blood cells or erythrocytes (RBC):
 Norma range is 5-6 milion/mm3.
 Hemoglobin (Hb) found in RBC and carrying O2,
normal value for hemoglobin is 13-15 gm/100ml in
males and 12-14gm /100ml in females.
2. White blood cells or leukocytes (WBC):
 Normal range 4.500-11000/ cubic millimetre.

Function: defence against organisms.
3.
Platelets or Thrombocytes:

Normal range: 150.000-400.000.

Help control bleeding.
b.
Plasma:

Liquid of the blood remain after removal of blood
cells (55%).

Help in circulation of the blood.

Composition of plasma:
i. Serum: fluid remaining when plasma allowed to
clot.
ii.Plasma proteins: albumin, fibrinogen (important
in blood clotting), globulins (antibody and
clotting factors).
Blood Transfusion Therapy:
 When a transfusion is ordered, obtain the blood from the blood bank just before
starting the transfusion.
 Blood is administered through a 18-19 gauge intravenous needle or catheter.
 A Y-type blood administration set with an in line filter is used. One arm of the
administration set connects to blood; normal saline is attached to the other arm
of the Y-type set.
28
o Types of blood transfusion therapies include:
a) Whole blood transfusion:
 One unit of whole blood consists of 450 mL.
 Blood stored for more than 6 hours doesn’t provide a
therapeutic platelet transfusion or coagulation factors (ie,
factors V and VIII).
b) Blood component therapy:
 Involves transfusion of a specific portion of blood lacking in
a patient.
 Blood components:
1) Red blood cells.
2) Leukocytes.
3) Platelets.
4) Fresh frozen plasma.
5) Clotting factors.
 Advantages of blood component therapy include:
1) Avoiding the risk of sensitizing the patient to other
blood components.
2) Providing optimal therapeutic benefit while reducing
risk of volume overload.
3) Increasing availability of needed blood products to
larger population.
o Blood must be checked for (Before transfusion):
1. History of viral hepatitis and history or possible exposure to AIDS.
2. History of exposure to infectious disease within the last month.
3. Cross-match and compatibility with patient blood .

A transfusion should be completed within 4 hours of initiation.
o Start administration slowly (no more than 25- 50 ml for the first 15
minutes). Stay with the patient for the first 5-15 minutes of
transfusion.
o Check vital signs /5 minutes for the first half hour after the start of
the transfusion and then / 1/2 hour or hour after the transfusion
depending on agency policy. Any change in vital signs during the
transfusion may indicate a reaction.
o Increased infusion rate (If no adverse effects during the first half
hour).
o Observe patient for flushing, dyspnea, itching, rash.
29
o Complications of blood transfusion:
1. Haemolytic transfusion reaction:
 Is a life-threatening complication result from transfusion of
donor blood that is incompatible with the recipient's blood.
(Antibodies in the recipient's plasma combine with antigens
on donor erythrocytes, causing agglutination and hemolysis
or vies versa).
2. Febrile, nonhemolytic transfusion reaction:
 Sensitivity to leukocyte or platelet antigens.
 The most common type of reaction.
3. Septic reaction:
 Result from transfusion of a blood contaminated with
bacteria.
4. Allergic reactions:
 May result from sensitivity to plasma protein or donor
antibody.
5. Circulatory overload:
 Results from administration at a rate or volume greater than
can be accommodated by the circulatory system.
 Precipitate congestive heart failure or pulmonary oedema.
6. Infectious diseases:
 Include:
1. Hepatitis B and C.
2. Malaria.
3. Syphilis.
4. AIDS.
7. Reactions associated with massive transfusions:
 More than 10 units of packed RBC within 1 to 6 hours):
1. Hyperkalemia.
2. Hypothermia.
3. Arrhythmias .
4. Cardiac arrest.
o Nursing management:
1. Prevent transfusion reaction:
a. Verify patient identification, beginning with type match
sample collection and labelling to double-check. verify
consent form for blood transfusion.
30
b. Inspect the blood product for gas bubbles, clotting, or
abnormal colour before administration.
c. Begin transfusion slowly (10 drops/minute) and observe the
patient during the first 15 minutes. Take vital signs / 5
minutes for the first 15 minutes.
d. Transfuse blood within 4 hours (or 2 hours if no signs of
fluid over load) and change blood tubing (Y-tubing) every 2
units ( risk growth of bacteria).
e. Prevent hypothermia by warming blood unit to 37°C before
transfusion.
2. Action to be taken after detecting any signs or symptoms of reaction:
a. Stop the transfusion immediately, and notify the physician.
b. Keep vein open (KVO).
c. Send the blood hag and tubing to the blood bank for repeat
typing.
d. Draw another blood sample for plasma haemoglobin, culture,
and retyping.
31
Introduction to Clinical Skills
Unit Five
Introduction to nutrition
Special diets:
o NPO:
 Patient is fasts for surgery or procedure.
o Clear liquid diet:
 Like water, tea, coffee, clear juice, ….provided for patient after
certain surgery or an acute stage of infection specially in GI tract.
o Full liquid diet:
 Liquids or food turn to liquid at body temperature like ice cream.
 It's given for patient with gastrointestinal disturbance.
o Soft diet:
 Is easily chewed and digest like chesses, potato.
 It's given for patient have difficulty in chewing and swallowing.
o Diet as tolerated:
 It's given when the patient appetite, ability to eat, and tolerance for
certain food may be change.
 For example, after surgery patient may be given clear liquid, if no
nausea, full liquid or even regular diet may be given.
o Diet Modification for Disease:
 Diabetic diet: for patient with DM.
 Low salt diet: for patient with hypertension.
 Low cholesterol diet: for patient with coronary heart disease.
 Low protein diet: for patient with renal failure.

Alternative feeding method:
o Enteral: through gastrointestinal system.
o Parenteral: intravenous.

Enteral Feeding:
o Nasogastric tube.
o Nasointestinal tube.
o Gastrostomy tube.
o Jejunostomy tube.
o Enteral Feeding can be given intermittently or continuously.
o A stander formula provide 1 Kcal per ml of solution which contain protein,
fat, carbohydrate, mineral and vitamins.

Parenteral Nutrition:
o
TPN is an intravenous technique used to provide for the nutritional needs of the
patient who cannot or should not digest or absorb nutrients via the GI tract.
o TPN is administered through central vein only (like superior vena cava).
32

o TPN consist of:
 Dextrose 5% or 10% or 25%.
 Protein.
 Fat.
 Electrolytes.
 Vitamins.
 Trace elements.
o Give TPN as the method of giving the IV fluid with the following
considerations:
 Monitor intake and output, monitor vital signs, measure blood
glucose (finger stick) every 6 hours, maintain constant intravenous
flow rate.
 Monitor insertion site and report any evidence of redness/ swelling,
or tenderness.
 Maintain sterile occlusive TPN dressing & change intravenous
dressing as protocol.
 Change TPN solution and tubing at least every 24 hours.
 If infusion is interrupted, infuse 10% dextrose of water until TPN is
restarted.
 Keep TPN solution refrigerated until needed.
 Never use TPN line for administering medications, drawing blood,
or taking CVP readings.
 Use filter and infusion device per policy.
 Weight patients at regular intervals & monitor serum electrolytes &
albumin levels.
Stoma:
o Stoma:
 Is an opening on the abdomen (suturing mucosa of the intestine to
the skin) made to eliminate faces through it related to inflammatory
bowel disease, injury, intestinal surgery (temporary), and cancer
(permanent).
 Patient with Stoma wear an external pouch to collect emerging fecal
matter, which will be watery or pasty.
 Pouch helps to control odor and protect the stoma and peristomal
skin. Disposable pouching systems can be used for'7 days and may
be adhesive.
 It is important to teach patient to avoid odor-causing foods, such
fish, eggs, onions.
 Main type:
 Colostomy:
o Use mucosa of colon (large intestine).
 Ileostomy:
o Use mucosa of ileum (small intestine)
33
Introduction to Clinical Skills in Patient Care
Unit Six
Elimination
Bowel Elimination:

Physical Assessment of the Abdomen:
o Inspection — observe contour, any masses, scars, or distention.
o Auscultation — listen for bowel sounds in all quadrants:
 Note frequency and character, audible clicks and flatus.
 Describe bowel sounds as audible, hyperactive, hypoactive, or
inaudible.
o Percussion — expect resonant sound or tympany:
 Areas of increased dullness may be caused by fluid, a mass, or
tumor.
o Palpation — note any muscular resistance, tenderness, enlargement of
organs, masses.

Physical Assessment of the Anus and Rectum:
o Inspection and palpation:
 Examine anal area for cracks, nodules, distended veins, masses,
or polyps, fecal mass.
 Insert gloved finger into anus to assess sphincter tone and
smoothness of mucosal lining.
 Inspect perineal area for skin irritation secondary to diarrhea.

Stool Collection:
o Medical aseptic technique is imperative.
o Wear disposable gloves.
o Wash hands before and after glove use.
o Do not contaminate outside of container with stool.
o Obtain stool and package, label, and transport according to agency
policy.

Patient Guidelines for Stool Collection:
o Void first so urine is not in stool sample.
o Defecate into the container rather than toilet bowl.
o Do not place toilet tissue in the bedpan or specimen container.
o Notify nurse when specimen is available.

Methods of Emptying the Colon of Feces:
o Enemas.
o Rectal suppositories.
o Rectal catheters.
o Digital removal of stool.
34

Types of Enemas:
o Cleansing.
o Retention.
o Return-flow.

Retention Enemas:
o Oil-retention — lubricate the stool and intestinal mucosa easing
defecation.
o Carminative — help expel flatus from rectum.
o Medicated — provide medications absorbed through rectal mucosa.
o Anthelmintic — destroy intestinal parasites.
o Nutritive — administer fluids and nutrition rectally.

Colostomy Care:
o Keep patient as free of odors as possible; empty appliance frequently.
o Inspect the patient’s stoma regularly:
 Note the size, which should stabilize within 6 to 8 weeks.
 Keep the skin around the stoma site clean and dry.
 Measure the patient’s fluid intake and output.
o Explain each aspect of care to the patient and self-care role.
o Encourage patient to care for and look at ostomy.

Patient Teaching for Colostomies:
o Community resources are available for assistance.
o Initially encourage patients to avoid foods high in fiber.
o Avoid foods that cause diarrhea or flatus.
o Drink two quarts of water daily.
o Teach about medications.
o Teach about odor control (intake of dark green vegetables).
o Resume normal activity including work and sexual relations.
Urinary Elimination:

Physical Assessment of Urinary Functioning:
o Kidneys — check for costovertebral tenderness.
o Urinary bladder — palpate and percuss the bladder or use bedside
scanner.
o Urethral meatus — inspect for signs of infection, discharge, or odor.
o Skin — assess for color, texture, turgor, and excretion of wastes.
o Urine — assess for color, odor, clarity, and sediment.
35

Measuring Urine Output:
o Ask patient to void into bedpan, urinal, or specimen container in bed or
bathroom.
o Pour urine into appropriate measuring device.
o Place calibrated container on flat surface and read at eye level.
o Note amount of urine voided and record on appropriate form.
o Discard urine in toilet unless specimen is needed.

Urine Specimens:
o Routine urinalysis.
o Specimens from infants and children.
o Clean-catch or midstream specimens.
o Sterile specimens from indwelling catheter.
o 24-hour urine specimen.

Reasons for Catheterization:
o Relieving urinary retention.
o Obtaining a sterile urine specimen.
o Measuring amount of PVR urine in bladder.
o Emptying bladder before during or after surgery.
o Monitoring of critically ill patients.
36
Introduction to Clinical Skills in Patient Care
Unit Seven
Operative Nursing Care
Operative nursing care:
 Operative nursing care is the nursing care that includes providing of care in:
o Before operation (preoperative).
o During operation (intraoperative).
o After operation (postoperative).
Type of surgery:
 Planned.
 Unplanned.
Preoperative Nursing Care:

Day before surgery:
o Provide emotional support and answer questions.
o Follow preoperative dietary restrictions (NPO or nothing by mouth 6-8 h
before surgery).
o Prepare for elimination needs during and after surgery.
o Shave and prepare the preoperative site.
o Check vital signs and weight accurately.
o Signs the patient or responsible person on Consent Form.
o Complete Data base/admission assessment form.
o Do the blood investigations and other test (according to the policy) &
check results.
o Prepare patient physically and emotionally for operation.
o Provide I.V nutrition and hydration (as order).
o Teach patient about surgery, deep breathing, coughing exercise,
postoperative equipment and monitoring devices.

Day of surgery:
o Check that proper identification band is on patient hand.
o Check that preoperative consent forms are signed and medical record is in
order.
o Check vital signs (notify physician for changes in BP, temperature, cough,
symptoms of infection).
o Remind patient not to swallow water if NPO for surgery.
o Provide I.V nutrition and hydration (as order).
o Remove cosmetics and prostheses (i.e., contact lenses, dentures…).
o Have patient empty bladder and bowel prior to surgery.
o Place valuables in appropriate area (hospital safety department).
o Provide special preoperative order (preoperative medication, special
procedure…).
o Complete preoperative checklist, and record the patient's preoperative
preparation.
37

o Wear a patient the gown, cap.
o Check that diagnostic test results are available.
o Notes:
 Outpatient surgery: patient may perform some preoperative
preparations at home.
 A parent must sign a consent form for a child.
Intraoperative Period:
o Types of Anesthesia:
 General Anesthesia.
 Local Anesthesia.
 Topical Anesthesia.
 Epidural Anesthesia.
 Nerve block Anesthesia.
o Types of nurses work in operation room:
 Scrub nurse:
 Responsibilities:
o Prepare all instruments.
o Ensures the sterility of the surgical field.
o Help the surgeon during the surgery.
 Circulating nurse:
 Responsibilities:
o Make sure that the operating room is adequately
supplied.
o Provide any additional supplies to the scrub nurse
during the operation.
o Nursing Intervention:
 Ask the patient about any known allergies.
 Verify patient identification and that the correct surgery is
scheduled.
 Antidote supplies (of anaesthesia) must be available in an
emergency room.
 Promote measures that ensure adequate tissue perfusion:
 Assess the patient's vital signs continuously, respiratory
status, peripheral vascular status, and cardiovascular status.
 Assist with mechanical ventilation.
 Promote measures that maintain adequate fluid and electrolyte
balance:
 Monitor intake and output accurately.
 Assess for skin turgor and mucous membranes (sings of
dehydration) and circulatory overload (breath sounds,
peripheral oedema, & jugular vein distension).
 Promote measures that maintain the patient's normal temperature:
 Ensure that OR temperature is between 25°C and 26.6°C.
38




Warm all intravenous and irrigating solutions.
Monitor the patient's temperature continuously.
Remove all wet gowns and drapes promptly and replace
with dry to prevent heat loss.
 Promote measures that decrease risk of infection:
 Maintain sterile procedures and techniques during surgery.
 Apply sterile dressings to all wounds.
 Non-scrubbed personnel refrain from touching or
contaminating anything that is sterile.
 Ensure patient's safety in the OR:
 Remove any potential contaminants.
 Recheck electrical equipment for proper operation.
 Make sure that necessary equipment and supplies are
available.
 Count and record sutures, needles, instruments, and
sponges.
 Assist in transferring the patient to the OR table.
 Cover the patient with a warm blanket, and attach the safety
belt.
 Remain at the patient's side during anaesthesia induction.
 Verify proper patient positioning to protect nerves,
circulation, respiration, and skin.
 Ensure that newly requested items are quickly supplied to
the anaesthesia or scrub team by the circulating nurse.
Postoperative Period:
o The Immediate Postoperative care: Recovery Room:
 Goals:
 Adequate tissue perfusions.
 Maintenance of airway patency & function.
 Absence of postoperative complication.
 Prevent of complications of immobility.
 Nursing Interventions:
 Assess and provide intervention for the following at least
15 minutes:
o Airway (Maintain Airway patency and optimal
respiratory function).
o Vital signs (every 5 minutes for 3 times then
every15 minute).
o General appearance, Level of consciousness (LOC),
and movement of extremities.
o Pain level (administers medication).
o Urine output, drain or catheter patency.
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o Intravenous or central line patency.
o Observe operative site, dressing, and drainage for
haemorrhage.
o Function of cardiac and oxygen monitor.
o Later Postoperative care (in department):
 Nursing intervention:
 Assess the patient's level of consciousness.
 Place the patient in a safe position on the side with face
down & neck slightly extended (prevents aspiration of
vomitus & airway obstruction).
 Monitor vital signs:
o Every 15 minutes the first hour.
o Every 30 minutes the next 2 hours.
o Every hour for next 4 hours.
o Finally, every 4 hours.
 Assess skin colour and condition and provide warmth.
 Check dressings for colour, amount of drainage, and check
for bleeding.
 Maintain the intravenous infusion at the correct rate.
 Provide for a safe environment (bed in the low position
with side rails up and functioning calling system).
 Relieve pain by administering medications.
 Promote optimal respiratory function:
o Coughing and deep breathing exercises.
o Early ambulation, ROM, and frequent position
change.
o Administration of oxygen as ordered.
 Assess elimination status:
o Promote voiding by offering bedpan or urinal at
regular intervals.
o Monitor catheter drainage & measure intake and
output.
 Promote optimal nutritional status:
o Assess for return of peristalsis.
o Encourage fluid intake and diet (as ordered).
 Promote wound healing by use surgical asepsis & providing
wound care.
 Provide periods of rest.
 Provide psychological support.
 Verify that all tubes are patent and equipment is operative.
 Provide other specific postoperative orders.
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Introduction to Clinical Skills in Patient Care
Unit Eight
Wound Care
Degree of contamination:
 Clean wounds:
o Are uninfected wounds in which minimal inflammation exist, are primarily
closed wounds.
 Clean – contaminated wound:
o Are surgical wounds in which the respiratory, alimentary, genital, or
urinary tract has been entered.
o There is no evidence of infection.
 Contaminated wounds:
o Include open, fresh, accidental wounds.
o There is evidence of inflammation.
 Dirty or infected wounds:
o Includes old, accidental wounds containing dead tissue and evidence of
infection such as pus drainage.
Types of wounds:
 Incision:
o Open wound, painful, deep or shallow, due to sharp instrument.
 Contusion:
o Closed wound, skin appears ecchymotic because of damaged blood
vessels, due to blow from blunt instrument.
 Abrasion:
o Open wound involving skin only, painful, due to surface scrape.
 Puncture:
o Open wound, penetrating of the skin and often the underlying tissues by a
sharp instrument.
 Laceration:
o Open wound edges are often jagged, tissues torn apart. Often from
accidents.
 Stab wound:
o Open wound, penetration of the skin and the underlying tissues, usually
unintentional.
Pressure Ulcer:
 Pressure ulcer are also called bedsore.
 A pressure ulcer is any lesion caused by unrelieved pressure that results in damage
to underlying tissue.
 Risk Factors:
o Immobility and inactivity.
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o Inadequate nutrition (specifically, inadequate intakes of protein,
carbohydrates, fluids, and vitamin C).
o Fecal and urinary incontinence: because moisture make the skin easily to
break and injury.
o Decreased mental status: because there is decreased in the respond to the
pain associated with prolonged pressure.
o Diminished sensation: paralysis or other neurologic disease may cause loss
of sensation in a body area.
o Other factors as: incorrect positioning, poor reposition, and repeated
injections in the same area.
Wound Healing:
 Healing is regeneration (renewal) of tissues.
 The time needed for healing depends on location, and size of wound, and health
status of the client.
 Complications of wound healing:
o Hemorrhage:
 Some escape of blood from a wound is normal, but persistent
bleeding is abnormal.
o Hematoma:
 Localized collection of blood underneath the skin, and may appear
as a reddish blue swelling.
o Infection.
 Factors affecting wound healing:
o Developmental considerations (child and elderly).
o Nutrition: epically protein, carbohydrates, lipids, Vitamin A and C, and
minerals.
o Lifestyle: regular exercises enhance healing.
o Medications: such anti-inflammatory drugs.
o Contamination and infection: it’s delay the healing process.
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Introduction to Clinical Skills in Patient Care
Unit Nine
Documentation and Reporting
Documenting nursing activates:
 Admission nursing assessment.
 Nursing care plans.
 Kardex (written pencil).
 Flow sheets:
o Graphic clinical record.
o Fluid balance record.
o Medication record.
 Progress note.
 Nursing discharge record.
Guide line for recording:
 Date and time:
o Document the date and time of each recording.
 Timing:
o Documentation should be done as soon as possible after an assessment
or intervention ,no recording should be done before providing nursing
care.
 Legibility:
o Must be legible and easy to read to prevent interpretation error.
 Permanence:
o All entries on the client record are made in dark ink.
 Accepted terminology:
o Use only commonly accepted ,symbols ,and term that are specific by
the agency.
 Correct spelling.
 Signature:
o Each recording on the nursing note is signed by the nurse making.



Accuracy:
o The client name and identifying information should written on each
page of the clinical record.
o Notation on record must be accurate and correct.
o Accurate notation consist of facts and observation rather than opinion
or interpretation.
o Avoid general word such as large, good, or normal.
o Write in every line but never between line.
Sequence.
Appropriateness:
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


o Record only information that parties to the clinical health problem and
care and not personal information.
Completeness.
Conciseness:
o Recording need to be brief as well as complete.
Legal prudence:
o accurate, complete documentation should give legal protection to the
nurse.
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