Basics in Nursing Care
Basics in Nursing Care
Prepared By
Dr. Abdul-Monim Batiha RN, DNSc
Assistant professor of Critical Care Nursing
2010-2011
Unit 1
Introduction to nursing care
 Definitions of Nursing
 Definitions of nursing include nursing as caring, an art, a science,
client centered, holistic, adaptive, a helping profession, and
concerned with health promotion, maintenance, and restoration.
The definition of nursing developed by the American
Nurses Association has evolved over the years. The current
definition states that “nursing is the protection, promotion, and
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optimization of health and abilities, prevention of illness and
injury, alleviation of suffering through the diagnosis and
treatment of human response, and advocacy in the care of
individuals, families, communities, and population.”
 Consumer , patient , and client are terms used to identify the
recipients of nursing; however, many nurses use the term client since
it emphasizes the responsibility of people for their own health.
 Discuss historical Back Ground influencing the development of
nursing.
Many nursing leaders have made contributions to nursing’s history
and to women’s history.
Florence Nightingale (1820–1910) was the founder of modern
nursing.
Clara Barton (1812–1912) helped establish the American Red
Cross.
Linda Richards (1841–1930) was the United States’ first trained
nurse and is credited with pioneer work in psychiatric and industrial
nursing.
Mary Mahoney (1845–1926) was the United States’ first black
professional nurse, and she worked for acceptance of blacks into
nursing and the promotion of equal rights.
Lillian Wald (1867–1940) was the founder of public health nursing
and with Mary Brewster founded the Henry Street Settlement and
Visiting Nurse Service.
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 Identify four major areas within the scope of nursing practice.
1.
Four major areas within the scope of nursing practice are promoting
health and wellness, preventing illness, restoring health, and caring for the
dying.
Promoting health and wellness involves behaviors that enhance
quality of life and maximize personal potential by enhancing healthy
lifestyles.
The goal of illness prevention is to maintain optimal health by
preventing disease.
Restoring health includes providing direct care, performing diagnostic
and assessment procedures, consulting with other health care professionals,
and teaching and rehabilitating clients.
Care of the dying involves comforting and caring for dying clients,
assisting clients to live as comfortable as possible until death, and helping
support persons cope with death.
 Identify Levels of Communication and discus
interpersonal
relationship
Communication occurs at different levels, with each level influencing the
others. Discussed below are the intrapersonal, the interpersonal, and group
levels of communication.
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Intrapersonal Level
Intrapersonal communication is the messages one sends to oneself, including
self-talk, or communication with oneself. A person receiving internal or
external messages organizes, interprets, and assigns meaning to the
messages.
The result of this process is the individual’s unique way of perceiving.
The message of the speaker may differ from that heard by the receiver
because of the intrapersonal communication of each. Also, self-talk can
interfere with attention to others and cause much to be missed during
interpersonal exchanges.
Interpersonal Level
Interpersonal communication is the process that occurs between two people
either in face-to-face encounters, over the telephone, or through other
communication media. Interpersonal communication builds on the
intrapersonal level in that each person communicating must communicate
with the self in order to communicate with others. An important outcome of
interpersonal communication is the development of an interpersonal
relationship .
Interpersonal skills are essential competencies for nurses.
 Describe the duties (roles) of nurses.
 Nurses assume a number of roles, often concurrently, while providing
care to clients. These roles include caregiver, communicator, teacher,
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client advocate, counselor, change agent, leader, manager, case
manager, and research consumer.
As caregivers, nurses perform activities that assist the client
physically and psychologically.
As communicators, nurses communicate with clients, support
persons, other health care professionals, and people in the community.
As educators, nurses educate clients about their health and health
care procedures, teach unlicensed assistive personnel, and share expertise
with other nurses and health care personnel.
As client advocates, nurses act to protect clients. They represent
clients’ needs and wishes to other health professionals and assist clients to
exercise rights and speak up for themselves.
As
counselors,
nurses
provide
emotional,
intellectual,
and
psychological support to help clients recognize and cope with stressful
psychological or social problems, develop improved interpersonal
relationships, and promote personal growth.
As change agents, nurses not only assist clients to make
modifications in behavior but also act to make changes in the health care
system.
As leaders, nurses influence others to work together to accomplish
specific goals whether working with individual clients, other health
professionals, or community groups.
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As managers, nurses manage care for individuals, families, and
communities. They delegate nursing activities to ancillary personnel and
other nurses, supervising and evaluating their performance.
As case managers, nurses work with multidisciplinary health care
teams to measure effectiveness of case management plans and to monitor
outcomes.
As research consumers, nurses are aware of the process of research,
are sensitive to protection of the rights of human subjects, participate in the
identification of researchable problems, and discriminately use research
findings to improve client care.
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Unit 2
Management of some of the nursing processes
Vital Signs
Base line vital signs
*
Introduction:Vital signs are an important element of the assessment process, they are
indictors of the patients present condition , baseline vital signs includes:
1- Respiration.
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234-
Pulse.
Blood pressure.
Body temperature.
Other key indications of
the patient’s respiratory, cardiovascular and central nervous system are:1. Capillary refill
2. Papillary reaction
3. Level of consciousness
1-
Body temperature:It reflect the balance between the heat produced and the lost from the
body, the average body temp of an adult is between ( 36.7-37c) . There
are four common sites for measuring body temperature.
a. Oral route:- Most accessible and convenient and contra indicated for
1. Children under 6 yrs of age
2. For patients who are confused
3. For patients who have convulsive disorders
4. For patients following oral surgery.
b. Rectal route:- most reliable (accurate).
Contra indicated following:
1rectal surgery.
2newborn babies.
3patient with diarrhea.
c. Axillary route:- Safest and non invasive
d. Tympanic route:- Readily accessible very fast.
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2-
Respiration:
Breathing is continuous process in which each breath regularly follows the
last with no notable interruption, else it is normally spontaneous automatic
process that occurs with out conscious thought, visible effort , marked
sounds or pain, you will assess breathing by watching the patient’s chest
rise and fall, you must determine the:1. Rate:Are determined by counting the number of breath per a minute
normal respiratory rate varies according to age.
Newborn 30-60c/m
2 yrs 20-30 c/m
6 yrs 18-26 c/m
Adult 12-20 c/m
2. quality :see the table below (characteristics of respiration):
Normal
Shallow
Noisy
wheezing
3.
4.
3-
characteristics of respiration
Breathing is neither shallow nor deep
Average chest wall motion
No use of accessory muscles
Slight chest or abdominal wall motion
Labored Increased breathing effort
Grunting, stridor
Use of accessory muscles possible gasping
Nasal flaring, supraclavicular and intercostals
retractions in infants and children
Increase in sound of breathing, including snoring,
Rhythm:- regular or irregular.
Depth :- shallow
Pulse
A wave of blood created by contraction of the left ventricles of the heart,
the heart is pulsating pump and the blood enter the arteries with the heart
beat causing pulse wave. You must assess the rate, strength and
regularity of the pulse.
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Blood pressure
Arterial blood pressure is define as a measure or the pressure exerted by
the blood as it flows through the arteries there are 2 blood pressure measures:1. Systolic pressure:- Is the pressure of the blood as a result of
contraction of the ventricles.
2. Diastolic pressure:- Is the pressure when the ventricles are at rest.
The average blood pressure of a healthy adult is 120/80 mm Hg.
 Hypertension:- is abnormally high blood pressure over 140 mm Hg
systolic and 90 mm Hg diastolic.
 Hypotension:- Is abnormally low blood pressure below 100 mm Hg
systolic and 60 mm Hg diastolic.
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Types of Thermometers
• Electronic
• Chemical disposable
• Infrared (tympanic)
• Scanning infrared (temporal artery)
• Temperature-sensitive tape
•
Glass mercury
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Pulse Sites
A pulse may be measured in nine sites (Temporal. Carotid. Apical.
Femoral. Brachial. Redial. Popliteal. Posterior tibial. Dorsalis pedis).
When assessing the pulse, the nurse collects the
following data:
 Tachycardia. An excessively fast heart rate over 100 BPM in adult is
referred to as tachycardia.
 Bradycardia. A heart rate in an adult of 60 BPM or less is called.
 The pulse rhythm. Is the pattern of the beats and the intervals between
the beats. Equal time elapses between beats of a normal pulse. A pulse
with an irregular rhythm is referred to as a dysrhythmia or arrhythmia.
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 Pulse volume, also called the pulse strength or amplitude, refers to the
force of blood with each beat.
 The elasticity of the arterial wall reflects its expansibility or its
deformities. A healthy, normal artery feels straight, smooth, soft, pliable.
Respirations
Respiration is the act of breathing. External respiration refers to the
interchange of oxygen and carbon dioxide between the alveoli of the lungs
and pulmonary blood. Internal respiration, by contrast, takes place
throughout the body; it is the interchange of these same gases between the
circulating blood and the cells of the body tissues.
Inhalation or inspiration refers to the intake of air into the lungs.
Exhalation or expiration refers to breathing out or the movement of gases
from the lungs to the atmosphere. Ventilation is also used to refer to the
movement of air in and out of the lungs.
Altered Breathing Patterns and Sounds
1. Breathing Patterns
Rate
 Tachypnea -----quick, shallow breaths.
 Bradypnea------abnormally slow breathing.
 Apnea-------------cessation of breathing.
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Volume
 Hyperventilation------overexpansion of the lungs characterized by
rapid and deep breath.
 Hypoventilation-------under-expansion of the lungs, characterized
by shallow respirations.
Ease or Effort
 Dyspnea -----difficult and labored breathing during which the
individual has a persistent, unsatisfied need for air and feels
distressed.
 Orthopnea-------ability to breathe only in upright sitting or
standing positions
Blood Pressure
Blood pressure
Arterial blood pressure is a measure of the pressure exerted by the
blood as it flows through the arteries. Because the blood move in waves.
There are two blood pressure:
 Systolic pressure, which is the pressure of the blood as a result of
contraction of the ventricles, that is, the pressure of the height of
the blood wave.
 Diastolic pressure, which is the pressure when the ventricles are
at rest. Diastolic pressure is the lower pressure, present at all times
within the arteries.
 Pulse pressure, the difference between the diastolic and the
systolic pressures.
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Blood pressure is measured in millimeters of mercury (mmHg) and
recorded as a fraction. The systolic pressure is written over the diastolic
pressure. The average blood pressure of a healthy adult is 120/80 mm Hg.
Factors Affecting Blood Pressure
 Age : Newborns have a mean systolic pressure of about 75 mm Hg. The
pressure rises with age, reaching a peak at the onset of puberty, and then
tends to decline somewhat.
 Exercise: Physical activity increases the cardiac output and hence the
blood pressure, thus 20 to 30 minutes of rest following exercise is
indicated before the resting blood pressure can be reliably assessed.
 Stress: Stimulation of the sympathetic nervous system increases cardiac
output and vasoconstriction of the arterioles, thus increasing the blood
pressure reading. However, severe pain can decrease blood pressure
greatly by inhibiting the vasomotor center and producing vasodilatation.
 Race: African American males over 35 years have higher blood pressure
than European American males of the same age.
 Gender: After puberty, females usually have lower blood pressure than
males of the same age this difference is thought to be due to hormonal
variations. After menopause women generally have higher blood pressure
than before.
 Medication: Many medications may increase or decrease the blood
pressure.
 Obesity: Both childhood and adult obesity predispose to hypertension.
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 Diurnal variations: Pressure is usually lowest early in the morning,
when the metabolic rate is lowest, then rises throughout the day and
peaks in the late afternoon or early evening.
 Disease process: Any condition affecting the cardiac output blood
volume, blood viscosity and/or compliance of the arteries has a direct
effect on the blood pressure.
Hypertension: A blood pressure that is persistently above normal.
Primary hypertension an elevated blood pressure of unknown cause
Secondary hypertension an elevated blood pressure of known cause.
Hypotension is a blood pressure that is below normal.
Orthostatic hypotension is a blood pressure that falls when the client sits or
stands.
Common Errors in Assessing Blood Pressure
 Bladder cuff too narrow
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 Bladder cuff too wide
 Arm unsupported
 Insufficient rest before the assessment.
 Repeating assessment too quickly.
 Deflating cuff too quickly.
 Deflating cuff too slowly.
 Failure to use the same arm consistently.
 Arm above level of the heart.
 Assessing immediately after a meal or smoker or has pain.
Variations in Normal Vital Signs by Age
Age
Newborns
Oral
temperature
in degree
36.8
Pulse
Average
and Ranges
130
(80-
Respirations
Average and
Ranges
35(30-80)
Blood
pressure
(mm Hg)
73/55
180)
1 year
36.8
120
(80- 30 (20-40)
90/55
(75- 20 (15-25)
95/57
140)
5-8 years
37
100
120)
10 years
37
70 (50-90)
19 (15-25)
102/62
Teen
37
75 (50-90)
18 15-20)
120/80
Adult
37
80 (60-100)
16 (12-20)
120/80
Older adult
(>70 years)
37
70 (60-100)
16 (15-20)
Possible
increased
diastolic
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Injections
 Identify physiologic factors and individual variables affecting
medication action.
1Factors Affecting Medication Action

Developmental

Gender

Cultural, ethnic, and genetic

Diet

Environment

Psychologic

Illness and disease

Time of administration
1. Medication action may be affected by developmental factors, gender,
culture, ethnicity, genetics, diet, environment, psychologic factors, illness
and disease, and time of administration.
The nurse needs to be aware of developmental factors. Pregnant
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women must be careful about taking medications, especially in the first
trimester, because of the possible adverse effects on the fetus. Infants
usually require smaller doses because of their body size and the
immaturity of their organs. Older adults have different responses to
medications due to physiologic changes that accompany aging and
because they may be prescribed multiple drugs and incompatibilities may
occur.
Gender differences in medication action are chiefly related to the
distribution of body fat and fluid and hormonal differences. In addition,
most research studies on medications have been done on men.
In addition to gender, a client’s response to drugs is also influenced by
genetic
variations
such
as
size
and
body
composition
(pharmacogenetics).
Ethnopharmacology is the study of the effects of ethnicity on response
to prescribed medications. Cultural factors and practices (values and
beliefs) can also affect a drug’s action; for example, an herbal remedy
may speed up or slow down the metabolism of certain drugs (see
Culturally Competent Care).
The diet may contain nutrients that can interact with medications and
increase or decrease action.
It is important to consider the effects of a drug in the context of the
client’s personality, milieu, and environmental conditions (e.g.,
temperature, noise).
Psychologic factors, such as a client’s expectations about what a drug
can do, can affect the response to the medication.
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Illness and disease can affect how a client responds to a medication.
For example, aspirin can reduce body temperature of a feverish client but
has no effect on body temperature of a client without a fever.
Time of administration is important because medications are absorbed
more quickly if the stomach is empty; however, some medications irritate
the gastrointestinal tract and are given after a meal.
 Describe various routes of medication administration.
1 Routes of Medication Administration

Oral (PO)

Sublingual (SL)

Buccal

Parenteral
o
Subcutaneous (SC)
o
Intramuscular (IM)
o
Intradermal (ID)
o
Intravenous (IV)
o
Intra-arterial (IA)
o
Intracardiac (IC)
o
Intraosseous (IO)
o
Intrathecal (intraspinal) (IT) (IS)
o
Epidural (ED)
o
Intra-articular
2 Topical
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
Dermatological

Instillations and irrigations

Inhalation

Ophthalmic, otic, nasal, rectal, and vaginal
1.Routes of medication administration include oral, sublingual, buccal,
parenteral, and topical.
In oral administration the drug is swallowed. It is the most common,
least expensive, and most convenient route for most clients.
In sublingual administration a drug is placed under the tongue, where
it dissolves.
Buccal means “pertaining to the cheek.” In buccal administration a
medication is held in the mouth against the mucous membranes of the
cheek until the drug dissolves.
The parenteral route is defined as other than the alimentary or respiratory
tract. Some common routes for parenteral administration include
subcutaneous (hypodermic), into the subcutaneous tissue just below the
skin; intramuscular, into the muscle; intradermal, under the epidermis
(into the dermis); intravenous, into a vein; intra-arterial, into an artery;
intracardiac, into the heart muscle; intraosseous, into the bone;
intrathecal or intraspinal, into the spinal canal; epidural, into the epidural
space; and intra-articular, into a joint.
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2. Topical applications are those applied to a circumscribed surface area of
the body. Routes for topical applications include dermatologic, applied to
the skin; instillations and irrigations, applied into body cavities or orifices
such as the urinary bladder, eyes, ears, nose, rectum, or vagina;
ophthalmic, otic, nasal, rectal, and vaginal topical preparations; and
inhalations, administered into the respiratory system by a nebulizer or
positive
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pressure
breathing
apparatus.
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 Identify essential parts of a medication order.
1Parts of a Medication Order

Full name of the client

Date and time the order written

Name of drug to be administered

Dosage

Frequency of administration

Route of administration

Signature of person writing the order
 List examples of various types of medication orders.
1Types of Medication Orders and Examples

Stat order
o

Single order
o


Demerol 100 mg IM stat
Seconal 100 mg hs before surgery
Standing order
o
Multivitamin 1 capsule po daily
o
Demerol 100 mg IM q 4 h x 5 days
prn order
o
Amphojel 15 mL prn
- There are four common medication orders: stat order, single order,
standing order, and prn order.
A stat order indicates that the medication is to be given immediately and
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only once (e.g., Demerol 100 mg IM stat).
The single order or one-time order is for medication to be given once
at a specified time (e.g., Seconal 100 mg hs before surgery).
The standing order may or may not have a termination date, may be
carried out indefinitely (e.g., multiple vitamins daily) until an order is
written to cancel it, or may be carried out for a specified number of days
(e.g., Demerol 100 mg IM q4h × 5 days).
A prn order or as-needed order permits the nurse to give a medication
when, in the nurse’s judgment, the client requires it (e.g., Amphojel 15
mL prn).
 List six essential steps to follow when administering medication.
1Six Essential Steps for Administering Medications

Identify the client

Inform the client

Administer the drug

Provide adjunctive interventions as indicated

Record the drug administered

Evaluate the client’s response to the drug
1. When administering any drug, regardless of the route of administration,
the nurse must identify the client, inform the client, administer the drug,
provide adjunctive interventions as indicated, record the drug
administered, and evaluate the client’s response to the drug.
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JCAHO’s National Patient Safety Goals require a nurse to use at least
two client identifiers whenever administering medications. Acceptable
identifiers may be the person’s name, an assigned identification number,
a telephone number, a photograph, or another personal identifier.
If the client is unfamiliar with the medication, the nurse should
explain the intended action as well as any side effects or adverse
reactions that might occur. It is also very important to listen to the client.
Before administering the drug, the nurse should read the medication
administration record (MAR) carefully and perform three checks with the
labeled medication (See Box 35–3). In addition the ten “rights” of
medication administration must be observed (See Box 35–4).
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The nurse should provide adjunctive interventions as indicated.
Clients may require physical assistance in assuming positions for
parenteral medications or may need guidance about measures to enhance
drug effectiveness and prevent complications.
The nurse must record the drug administered, following agency
regulations.
In order to evaluate the client’s response to the drug, the nurse should
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know the kinds of behavior that reflect the action or lack of action of the
drug and its untoward effects (both minor and major) for each medication
the client is receiving. The nurse may also report the client’s response
directly to the nurse manager and primary care provider.
 State the “rights” to accurate medication administration.
1Ten “Rights” of Accurate Medication Administration

Right medication (Drug)

Right dose

Right time

Right route

Right client

Right documentation

Right client education

Right to refuse

Right assessment

Right evaluation
(See Box 35–4).
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 Identify equipment required for parenteral medications.
1 Parenteral Medications

Common nursing procedure

Absorbed more quickly than oral

Requires careful and accurate administration

Aseptic technique
2 Syringes

Parts
o
Ruber plunger Tip
o
Barrel
o
Plunger
3 Types of Syringes

Standard hypodermic syringe

Insulin syringe

Tuberculin syringe

Disposable prefilled unit-dose or prefilled cartridges
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4 Needles

Stainless steel

Most disposable

Parts
o
Hub
o
Cannula or shaft
o
Bevel
5 Characteristics of Needles

Slant or length of the bevel

Length of the shaft

Gauge
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 To administer parenteral medications, nurses use syringes and needles
to withdraw medications from ampules and vials.
 Syringes have three parts: the tip, the barrel, and the plunger. There
are several kinds of syringes, differing in size, shape, and material.
 The three most commonly used types are the standard hypodermic
syringe, the insulin syringe, and the tuberculin syringe. Injectable
medications are frequently supplied in disposable prefilled unit-dose
systems available as a prefilled syringe ready for use or prefilled
sterile cartridges and needles that require attachment to a reusable
holder. Needleless systems are also available.
 Needles are made of stainless steel, and most are disposable. A needle
has three parts: the hub, the cannula or shaft, and the bevel.
 Needles used for injections have three variable characteristics: the
slant or length of the bevel, the length of the shaft, and the gauge.
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 List the most common apprivation used in medications orders.
 Identify Guidelines for Safe Administration of Medications.
Guidelines for Safe Administration of Medications
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• Never administer medications that are prepared by another nurse. You are
responsible for a medication error if you administer a medication that was
inaccurately prepared by another nurse.
• Nurses should listen carefully to the client who questions the addition or
deletion of a medication. Most clients are aware of their prescribed
medications. If a client questions the drug or dose you are preparing to
administer, recheck the order.
• If a medication is withheld, indicate the exact reason why in the client’s
record. Legally you are accountable for giving ordered medications to the
client; however, circumstances may prevent you from giving a medication as
ordered. Medications may be held for some diagnostic tests, or the client
receiving antihypertensive medications may have a blood pressure that is
lower than normal. If you gave the antihypertensive, the blood pressure
would decrease, causing further hypotension.
• Do not leave medications at the client’s bedside for any reason. The client
may forget to take the medication, medications can accumulate, and the
client could take two or more of the same medication, causing an overdose,
or another client who is confused could take the medicine.
Do not leave medications at the client’s bedside for any reason. The client
may forget to take the medication, medications can accumulate, and the
client could take two or more of the same medication, causing an overdose,
or another client who is confused could take the medicine.
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Ampules and Vials
Drugs for parenteral injections are sterile preparations. Drugs that deteriorate
in solution are dispensed as tablets or powders and dissolved in a solution
immediately before injection. Drugs that remain stable in a solution are
dispensed in ampules and vials in an aqueous or oily solution or suspension.
Ampules are glass containers of single-dose drugs (Figure 29-13). The
glass container has a constriction in the stem to facilitate opening the
ampule.
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 Determine angle and site of injections.
Angle of Injection
The angle of insertion depends on the type of injection. Figure 29-18
illustrates the angle of insertion for each type of parenteral injection.
.
Intradermal Injection Sites: A. Inner Aspect of the Forearm; B. Upper
Chest; C. Upper Back
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Subcutaneous Injection Sites: A. Abdomen; B. Lateral and Anterior
Aspects of Upper Arm and Thigh; C. Scapular Area on Back; D.
Upper Ventrodorsal Gluteal Area.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
 Identify how to calculation of flow rate.
Calculation of Flow Rate
The flow rate is the volume of fluid to infuse over a set period of time
as prescribed by the health care practitioner. The health care
practitioner will identify either the amount to infuse per hour (such as
125 ml per hour or 1000 ml over an 8-hour period). Calculate the
hourly infusion rate as follows:
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Skill: Administering a Subcutaneous Injection
Preparation
1.
Assess:
• Allergies to medication.
• Specific drug action, side effects, and adverse
reactions.
• Client’s knowledge and learning needs about
the medication.
• Status and appearance of subcutaneous site
for lesions, erythema, swelling, ecchymosis,
inflammation, and tissue damage from
previous injections.
• Ability of the client to cooperate during the
injection.
• Previous injection sites used.
2.
Assemble equipment:
• MAR or computer printout
• Vial or ampule of the correct sterile
medication
• Syringe and needle
• Antiseptic swabs
• Dry, sterile gauze for opening an ampule
(optional)
• Clean gloves
Check the MAR.
Check the label on the medication
carefully against the MAR to make sure that the
correct medication is being prepared.
3.
Perfo
rmed
YNo
e
s
Mastered
Comments
Follow the three checks for
administering medications. Read the label on the
medication:
• When it is taken from the medication
cart
• Before withdrawing the medication
• After withdrawing the medication.
4.
Organize the equipment.
Procedure
1.
Perform hand hygiene and observe
other appropriate infection control procedures.
2.
Prepare the medication from the
ampule or vial for drug withdrawal.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
3.
4.
5.
6.
7.
8.
Provide for client privacy.
Prepare the client.
Introduce yourself and verify the
client’s identity.
Assist the client to a position in
which the arm, leg, or abdomen can
be relaxed, depending on the site to
be used.
Obtain assistance in holding an
uncooperative client.
Explain the purpose of the
medication and how it will help,
using language that the client can
understand. Include
relevant
information about effects of the
medication.
Select and clean the site.
Select a site free of tenderness,
hardness, swelling, scarring, itching,
burning, and localized inflammation.
Select a site that has not been used
frequently.
Put on clean gloves.
As agency protocol indicates, clean
the site with an antiseptic swab. Start
at the center of the site and clean in a
widening circle to approximately 5
cm (2 inches). Allow the area to dry
thoroughly.
Place and hold the swab between the
third and fourth fingers of the
nondominant hand, or position the
swab on the client’s skin above the
intended site.
Prepare the syringe for injection.
Remove the needle cap while waiting
for the antiseptic to dry. Pull the cap
straight off to avoid contaminating
the needle by the outside edge of the
cap.
Dispose of the needle cap.
Inject the medication.
Grasp the syringe in your dominant
hand by holding it between your
thumb and fingers. With palm facing
to the side or upward for a 45-degree
angle insertion, or with the palm
downward for a 90-degree angle
insertion, prepare to inject.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Using the nondominant hand, pinch
or spread the skin at the site, and
insert the needle, using the dominant
hand and a firm, steady push.
When the needle is inserted, move
your nondominant hand to the end of
the plunger.
9.
10.
11.
12.
Inject the medication by holding the
syringe steady and depressing the
plunger with slow, even pressure.
With many subcutaneous injections,
the needle should be imbedded within
the skin for five seconds after
complete depression of plunger to
ensure complete delivery of the dose.
Remove the needle.
Remove the needle slowly and
smoothly, pulling along the line of
insertion while depressing the skin
with your nondominant hand.
If bleeding occurs, apply pressure to
the site with dry, sterile gauze until it
stops.
Dispose of supplies appropriately.
Activate the needle safety device or
discard the uncapped needle and
attached syringe into designated
receptacles.
Remove gloves. Perform hand
hygiene.
Document all relevant information.
Document the medication given,
dosage, time, route, and any
assessments.
Many agencies prefer that medication
administration be recorded on the
medication record.
Assess the effectiveness of the
medication at the time it is expected
to act.
Variation: Administering a Heparin Injection
Procedure
Select a site on the abdomen away
from the umbilicus and above the
level of the iliac crests.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Use a ⅜-inch, 25- or 26-gauge needle,
and insert it at a 90-degree angle. If a
client is very lean or wasted, use a
needle longer than ⅜-inch, and insert
it at a 45-degree angle. The arms or
thighs may be used as alternate sites.
Do not aspirate when giving heparin
by subcutaneous injection.
Do not massage the site after the
injection.
Alternate the sites of subsequent
injections.
Skill: Administering an Intradermal Injection
Performed
Preparation
1.
2.
3.
Yes
No
Mastered
Comments
Assess:
• Appearance of the injection site.
• Specific drug action and the
expected response.
• Client’s knowledge of drug
action and response.
• Check agency protocol about
sites to use for skin tests.
Assemble equipment and supplies:
• Vial or ampule of the correct
medication
• Sterile 1-mL syringe calibrated
into hundredths of a milliliter
(i.e., tuberculin syringe) and a
25- to 27-gauge needle that is ¼–
⅝ inch long
• Alcohol swabs
• 2 x 2 sterile gauze square
(optional)
• Clean gloves (according to
agency protocol)
• Band-Aid (optional)
• Epinephrine
Check the MAR.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
4.
Check the label on the medication
carefully against the MAR to make
sure that the correct medication is
being prepared.
Follow the three checks for
administering medications. Read the
label on the medication:
• When it is taken from the
medication cart
• Before withdrawing the
medication
• After withdrawing the
medication
Organize the equipment.
Procedure
1.
2.
3.
4.
5.
6.
7.
8.
Perform hand hygiene and observe
other appropriate infection control
procedures.
Prepare the medication from the
vial or ampule for drug withdrawal.
Prepare the client.
Explain to the client that the
medication will produce a small
wheal, sometimes called a bleb.
Provide for client privacy.
Select and clean the site.
Select a site.
Avoid using sites that are tender,
inflamed, or swollen, and those that
have lesions.
Put on gloves as indicated by agency
policy.
Cleanse the skin at the site using a
firm, circular motion, starting at the
center and widening the circle
outward. Allow the area to dry
thoroughly.
Prepare the syringe for the injection.
Remove the needle cap while waiting
for the antiseptic to dry.
Expel any air bubbles from the
syringe.
Grasp the syringe in your dominant
hand, holding it between thumb and
forefinger. Hold the needle almost
parallel to the skin surface, with the
bevel of the needle up.
Inject the fluid.
With the nondominant hand, pull the
skin at the site until it is taut.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
9.
Insert the tip of the needle far enough
to place the bevel through the
epidermis into the dermis. The outline
of the bevel should be visible under
the skin surface.
Stabilize the syringe and needle, and
inject the medication carefully and
slowly, so that it produces a small
wheal on the skin.
Withdraw the needle quickly at the
same angle at which it was inserted.
Activate the needle safety device.
Apply a Band-Aid, if indicated.
Do not massage the area.
Dispose of the syringe and needle in
the sharps container.
Remove your gloves.
Circle the injection site with ink to
observe for redness or induration per
agency policy.
Document all relevant information.
Record the testing material given, the
time, dosage, route, site, and nursing
assessments.
Skill: Administering an Intramuscular Injection
Performed
Preparation
1.
2.
Yes
No
Mastered
Comments
Assess:
• Client allergies to medications.
• Specific drug action, side effects,
and adverse reactions.
• Client’s knowledge of and
learning needs about the
medication.
• Tissue integrity of the selected
site.
• Client’s age and weight, to
determine site and needle size.
• Client’s ability or willingness to
cooperate.
Determine:
• Whether the size of the muscle is
appropriate to the amount of
medication to be injected.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
3.
4.
5.
Assemble equipment and supplies:
• MAR or computer printout
• Sterile medication (usually
provided in an ampule or vial)
• Syringe and needle of a size
appropriate for the amount of
solution to be administered
• Antiseptic swabs
• Clean gloves
Check the MAR.
Check the label on the medication
carefully against the MAR to make
sure that the correct medication is
being prepared.
Follow the “three checks” for
administering the medication and
dose. Read the label on the
medication:
• When it is taken from the
medication cart
• Before withdrawing the
medication
• After withdrawing the
medication.
Confirm that the dose is correct.
Organize the equipment.
Procedure
1.
2.
3.
4.
Perform hand hygiene and observe
other appropriate infection control
procedures.
Prepare the medication from the
ampule or vial for drug withdrawal.
Whenever feasible, change the needle
on the syringe before the injection.
Invert the syringe needle uppermost,
and expel all excess air.
Provide for client privacy.
Prepare the client.
Check the client’s identification band.
Assist the client to a supine, lateral,
prone, or sitting position, depending
on the chosen site.
Obtain assistance in holding an
uncooperative client.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
5.
6.
7.
8.
Explain the purpose of the
medication and how it will help,
using language that the client can
understand. Include
relevant
information about effects of the
medication.
Select, locate, and clean the site.
Select a site free of skin lesions,
tenderness, swelling, hardness, or
localized inflammation, and one that
has not been used frequently.
If injections are to be frequent,
alternate sites. Avoid using the same
site twice in a row.
Locate the exact site for the injection.
Put on clean gloves.
Clean the site with an antiseptic
swab. Using a circular motion, start at
the center and move outward about 5
cm (2 inches).
Transfer and hold the swab between
the third and fourth fingers of your
nondominant hand in readiness for
needle withdrawal, or position the
swab on the client’s skin above the
intended site. Allow the skin to dry
prior to injecting medication.
Prepare the syringe for injection.
Remove the needle cover and discard
without contaminating the needle.
If using a prefilled unit–dose
medication, take caution to avoid
dripping medication on the needle
prior to injection. If this does occur,
wipe the medication off the needle
with sterile gauze.
Inject the medication using a
Z-track technique.
Use the ulnar side of the nondominant
hand to pull the skin approximately
2.5 cm (1 inch) to the side.
Holding the syringe between the
thumb and forefinger, pierce the skin
quickly and smoothly at a 90-degree
angle, and insert the needle into the
muscle.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
9.
10.
11.
12.
Hold the barrel of the syringe steady
with your nondominant hand, and
aspirate by pulling back on the
plunger with your dominant hand.
Aspirate for 5–10 seconds. If blood
appears in the syringe, withdraw the
needle, discard the syringe, and
prepare a new injection.
If blood does not appear, inject the
medication steadily and slowly
(approximately 10 seconds per
milliliter) while holding the syringe
steady.
After injection, wait 10 seconds.
Withdraw the needle.
Withdraw the needle smoothly at the
same angle of insertion. Release the
skin.
Apply gentle pressure at the site with
a dry sponge.
If bleeding occurs, apply pressure
with a dry, sterile gauze until it stops.
Activate the needle device or
discard the uncapped needle and
attached syringe into the proper
receptacle. Remove gloves. Perform
hand hygiene.
Document all relevant information.
Include the time of administration,
drug name, dose, route, and the
client’s reactions.
Assess effectiveness of the
medication at the time it is expected
to act.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Unit 3
Patient Care
Preoperative care &preparation for anesthesia
 Discuss various types of surgery according to degree of urgency,
degree of risk, and purpose.
1



Various types of surgery
Degree of urgency
o
Emergency
o
Elective
o
Major
o
Minor
Degree of risk
Purposes of surgical procedures
Dr. Abdul-Monim Batiha
o
Diagnostic
o
Palliative
o
Ablative
o
Constructive
o
Transplant
Page 55
Basics in Nursing Care
1. Surgery is classified by its urgency and necessity to preserve the
client’s life, body part, or body function. Emergency surgery is
performed immediately to preserve function or the life of the client
(for example, to control internal hemorrhage). Elective surgery is
performed when surgical intervention is the preferred treatment for a
condition that is not immediately life threatening, but may ultimately
threaten life or well-being, or to improve the client’s life (for example,
hip replacement surgery).
Surgery is also classified as major or minor according to the degree of
risk to the client. Major surgery involves a high degree of risk. It may be
complicated or prolonged, large losses of blood may occur, vital organs may
be involved, or postoperative complications may be likely (for example,
open heart surgery). Minor surgery normally involves little risk, produces
few complications, and is often performed on an outpatient basis (for
example, breast biopsy).
Surgical procedures have various purposes. A diagnostic procedure
confirms or establishes a diagnosis (for example, breast biopsy). A palliative
procedure relieves or reduces pain or symptoms of a disease; it does not cure
(for example, resection of nerve roots). An ablative procedure removes a
diseased body part (for example, removal of gallbladder). A constructive
procedure restores function or appearance that has been lost or reduced (for
example, breast implant). A transplant replaces malfunctioning structures
(for example, kidney replacement).
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
 Describe the phases of the perioperative period.
Surgery is a unique experience of a planned physical alteration
encompassing three phases: preoperative, intraoperative, and postoperative.
The preoperative phase begins when the decision to have surgery is
made and ends when the client is transferred to the operating table. The
nursing activities associated with this phase include assessing the client,
identifying potential or actual health problems, planning specific care based
on the individual’s needs, and providing preoperative teaching for the client,
the family, and significant others.
The intraoperative phase begins when the client is transferred to the
operating table and ends when the client is admitted to the postanesthesia
care unit (PAC). The nursing activities related to this phase include a variety
of specialized procedures designed to create and maintain a safe therapeutic
environment for the client and the health care personnel. The activities
include providing for the client’s safety, maintaining an aseptic environment,
ensuring proper functioning of equipment, and providing the surgical team
with the instruments and supplies needed during the operation.
The postoperative phase begins with the admission of the client to the
postanesthesia area and ends when healing is complete. During the
postoperative phase, nursing activities include assessing the client’s response
(physiologic and psychologic) to surgery, performing interventions to
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Basics in Nursing Care
facilitate healing and prevent complications, teaching, providing support to
the client and support people, and planning for home care.
 Identify essential aspects of preoperative assessment.
1. Preoperative assessment includes collecting and reviewing physical,
psychological, and social client data to determine the client’s needs
throughout the three preoperative phases.
Preoperative assessment data include current health status, allergies,
medications, previous surgeries, mental status, understanding of the surgical
procedure and anesthesia, smoking, alcohol and other mind-altering
substances, coping, social resources, and cultural and spiritual considerations
2. A brief but complete physical assessment pays particular attention to
systems that could affect the client’s response to anesthesia and
surgery. It also includes a brief “mini” mental status. Respiratory,
cardiovascular, and other systems (gastrointestinal, genitourinary, and
musculoskeletal) are examined to provide baseline data.
The surgeon and/or anesthesiologist orders preoperative diagnostic
tests. The nurse’s responsibility is to check the orders carefully to see that
they are carried out and to ensure that the results are obtained and in the
client’s record prior to surgery. Table 37–2 lists routine preoperative
screening tests. In addition to these tests, diagnostic tests directly relating to
the client’s disease are performed.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
 Identify nursing responsibilities in planning perioperative nursing
care.
1. The overall goal in the preoperative period is to ensure that the client
is mentally and physically prepared for surgery. Planning should
involve the client, the client’s family, and significant others.
Examples of nursing activities to achieve these goals include
preoperative teaching (covered in outcome 6), physical preparation
(covered in outcome 7), and psychological preparation.
For the perioperative client, discharge planning begins before admission.
Early planning to meet the discharge needs of the client is particularly
important for outpatient procedures as the client is generally discharged
within hours after the procedure is performed.
Discharge planning incorporates an assessment of the client’s, family’s, and
significant others’ abilities and resources for care, their financial resources,
and the need for referrals and home health services. (See Home Care
Considerations: Postoperative Instructions.)
2.
The overall goals of care in the intraoperative period are to maintain
the client’s safety and to maintain homeostasis. Examples of nursing
activities to achieve these goals include positioning the client appropriately;
performing preoperative skin preparation; assisting in preparing and
maintaining the sterile field; opening and dispensing sterile supplies during
surgery; providing medications and solutions for the sterile field; monitoring
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
and maintaining a safe, aseptic environment; managing catheters, tubes,
drains, and specimens; performing sponge, sharp, and instrument counts;
and documenting nursing care provided and the client’s response to
interventions.
3.
Overall goals in postoperative period include promotion of comfort
and healing; restoration of the highest possible level of wellness; and
prevention of associated risks. Postoperative care planning and discharge
planning begin in the preoperative phase when preoperative teaching is
implemented. To plan for continuity of care for the surgical client after
discharge, the nurse considers the client’s needs for assistance with care in
the home setting and incorporates an assessment of the client’s and family’s
abilities for self-care, financial resources, and the need for referrals and
home health services. (See Home Care Assessment: Surgical Clients.)
 Describe essential preoperative teaching, including pain control,
moving, leg exercises, and coughing and deep-breathing exercises.
1.
Four dimensions of preoperative teaching have been identified as
important to clients: information including what will happen to the
client, when it will happen, and what the client will experience,
such as expected sensations and discomfort; psychological support
to reduce anxiety; roles of the client and support people in
preoperative preparation, during the surgical procedure, and during
the postoperative period; and skills training such as moving, deep
breathing, coughing, splinting incisions with the hands or pillow,
and using an incentive spirometer.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Preoperative teaching includes instruction about preoperative and
2.
postoperative regimens.
Preoperative regimen teaching includes: need for preoperative testing;
discuss bowel preparation if necessary, skin preparation, preoperative
medications, specific preoperative therapies, visit by anesthetist, need to
restrict food and fluids, general timetable of events, need to remove jewelry,
makeup and prostheses, preoperative holding area and waiting room; teach
deep breathing and coughing exercises, how to turn, move, and splinting of
incisions.
Postoperative regimen teaching includes: explain PACU routine and
emergency equipment; review type and frequency of assessment; discuss
pain management; explain usual activity restrictions and precaution when
getting up for the first time postoperatively; describe usual dietary
alterations; discuss dressings and drains; and provide an explanation and
tour of ICU if client is to be transferred there postoperatively.
For outpatient surgical clients explain the usual preoperative and
postoperative regimens; confirm place and time of surgery, when to arrive,
where to register and what to wear; explain the need for a responsible adult
to drive or to accompany the client home; discuss medications; communicate
by telephone the evening before surgery to confirm time of surgery and
arrival time; communicate by telephone within 48 hours postoperatively to
evaluate surgical outcomes and identify any problems or complications.
3. The purposes for performing each of these skills include the following:
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Moving: to promote venous return, mobilize secretions, stimulate
gastrointestinal motility, and facilitating early ambulation.
Leg exercises: to promote venous return; prevent thrombophlebitis
and thrombus formation.
Deep breathing and coughing: to enhance lung expansion and
mobilize secretions; prevent atelectasis and pneumonia .
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
Unit 4
Morning & Evening Care of Surgical patient
 Describe essential aspects of preparing a client for surgery,
including morning care, evening care, nutrition and enema.
1.
Physical preparation includes the following: nutrition and fluids,
elimination, hygiene, medications, rest, care of valuables and
prostheses, special orders, vital signs, safety protocols, and surgical
skin preparation.
The nurse should identify and record any signs of malnutrition or fluid
imbalance. The nurse should also determine whether the client is to be “NPO
after midnight” or is permitted food or fluids as recommended by the
American Society for Anesthesiology (ASA) revised guidelines.
Enemas prior to surgery are no longer routine but may be ordered if
bowel surgery is planned. Prior to surgery, straight catheterization or the
insertion of an indwelling catheter into the urinary bladder may be ordered.
If the client does not have a catheter, the client should empty the bladder
prior to receiving preoperative medication.
The client may be asked to shower, bathe, and shampoo the evening
or morning of surgery (or both). The nails should be trimmed and free of
polish, and all cosmetics should be removed. Before going to the operating
room the client should remove all hair pins and clips, and put on an
operating room gown and surgical cap.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
The anesthetist or anesthesiologist may order routinely taken
medications be held the day of surgery as well as preoperative medications
which are given “on call” or at a scheduled time prior to surgery.
To promote rest and sleep, a sedative may be ordered the night before
surgery. The nurse should do everything possible to help the client sleep.
All prostheses must be removed before surgery. However, hearing
aids are often left in place and the operating room personnel are notified.
Valuables should be sent home with the client’s family or significant others
or be labeled and placed in a locked storage area per agency policy.
The nurse checks the surgeon’s orders for any special orders such as
insertion of a nasogastric tube, administration of medications, or application
of antiemboli stockings .
JCAHO has established the Universal Protocol for Preventing Wrong
Site, Wrong Procedure, Wrong Person Surgery. This involves three steps:
The first step is client verification at the time surgery is scheduled, during
admission, and repeated whenever the client is transferred to another
caregiver. The second step involves marking of the operative site in an
unambiguous manner. The third step is called “time-out.” The surgical team
takes a time-out to conduct a final verification of the correct client,
procedure, and site.
In most agencies skin preparation is carried out during the
intraoperative phase. The site is cleansed with an antimicrobial to remove
soil and decrease resident microbial count to subpathogenic levels.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
The nurse assesses and documents vital signs and reports abnormal
findings.
o Antiembolic stockings or sequential compression devices
(SCD) may be applied.
 Compare various types of anesthesia.
1.
2.
Anesthesia is classified as general, regional, or local.
General anesthesia is the loss of all sensation and consciousness.
Protective reflexes such as cough and gag reflexes are lost. General
anesthetics act by blocking awareness centers in the brain so that amnesia,
analgesia, hypnosis, and relaxation occur. They are generally administered
by intravenous infusion or by inhalation of gases.
3.
Regional anesthesia is the temporary interruption of the transmission
of nerve impulses to and from a specific area or region of the body. The
client loses sensation in an area of the body but remains conscious.
Techniques include the following: topical or surface (applied directly to the
skin and mucous membranes, open skin surfaces, wounds, and burns); local
or infiltration (injected into a specific area and used for minor surgical
procedures); nerve block (injected into and around a nerve or small nerve
group that supplies sensation to a small area of the body); intravenous block
or Bier block (used most often for procedures involving the arm, wrist, and
hand; an occlusion tourniquet is applied to the extremity to prevent
infiltration and absorption of the injected intravenous agent beyond the
involved extremity); spinal or subarachnoid block (agent is injected into the
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Basics in Nursing Care
subarachnoid space); epidural or peridural (injected into the epidural space);
and conscious sedation (minimal depression of the level of consciousness in
which the client retains the ability to maintain a patent airway and respond
appropriately to commands).
 Identify essential nursing assessments and interventions during
the immediate postanesthetic phase.
1- Essential nursing assessments during the immediate postanesthetic
phase include adequacy of airway; oxygen saturation; adequacy of
ventilation; cardiovascular status; level of consciousness; presence of
protective reflexes; activity; ability to move extremities; skin color;
fluid status; condition of operative site; patency of and amount and
character of drainage from catheters, tubes, and drains; discomfort;
and safety.
2.
Interventions include positioning the client on the side, with the
face slightly down; elevating the upper arm on a pillow; suctioning
as needed until cough and swallowing reflexes return; and helping
the client to cough and deep breathe once the oral airway or
endotracheal tube is removed. If the client has had spinal
anesthesia, keep the client flat for the specified period of time.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
 Demonstrate ongoing nursing assessments and interventions for
the postoperative client.
1- As soon as the client returns to the nursing unit, the nurse conducts an
initial assessment. The sequence of assessment varies with the
situation.
The nurse consults the surgeon’s postoperative orders for the following:
food and fluids, IV fluids and position, medications, laboratory tests, intake
and output and activity permitted. In addition, the nurse reviews the PACU
record for the following: operation performed, presence and location of
drains, anesthetic used, postoperative diagnosis, estimated blood loss, and
medications administered in the PACU.
The nurse assesses level of consciousness, vital signs, skin color and
temperature, comfort, fluid balance, dressing and bedclothes, and drains and
tubes.
3.
Nursing interventions designed to promote client recovery and
prevent complications include pain management, appropriate
positioning, incentive spirometry, deep breathing and coughing
exercises, leg exercises, early ambulation, adequate hydration, diet,
promoting urinary and bowel elimination, suction maintenance,
and wound care.
Dr. Abdul-Monim Batiha
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Basics in Nursing Care
 Identify potential postoperative complications and describe
nursing interventions to prevent them.
1- Potential postoperative problems and preventive nursing interventions
include: pneumonia (deep breathe, cough; moving in bed, early ambulation);
atelectasis (deep, breathe, cough, moving in bed, early ambulation);
pulmonary embolism (turning, ambulation, antiembolic stockings, SCD);
hypovolemia (early detection of signs, fluid and or blood replacement);
hemorrhage (early detection of signs); hypovolemic shock (maintain blood
volume through fluid replacement, prevent hemorrhage, early detection of
signs); thrombophlebitis (early ambulation, leg exercises, antiembolic
stockings, SCD, adequate fluid intake); thrombus (venous-same as
thrombophlebitis; arterial maintain prescribed position, early detection of
signs); embolus (turn, ambulate, leg exercises, SCD, careful maintenance of
IV catheters); urinary retention (monitor I&O, interventions facilitating
voiding, catheterization); urinary tract infection (adequate fluids, early
ambulation, straight catheterization, good perineal hygiene); nausea and
vomiting ( IV fluids until peristalsis returns, then progression of diet,
antiemetic drugs if ordered and analgesics); constipation (adequate fluids,
high fiber diet, early ambulation); tympanites (early ambulation, avoid using
straws, ice chips and water at room temperature); postoperative ileus (no
interventions listed); wound infection (keep wound clean and dry, use
surgical asepsis when changing dressings); wound dehiscence and
evisceration (adequate nutrition, appropriate incisional support and
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avoidance of strain); and postoperative depression (adequate rest, physical
activity, opportunity to express anger and other negative feelings).
 Describe appropriate wound care for a postoperative client.
1. Most clients return from surgery with a sutured wound covered by a
dressing. Dressings are inspected regularly to ensure that they clean,
dry and intact. Excessive drainage may indicate hemorrhage, infection
or an open wound.
When dressings are changed, the nurse assesses the wound for
appearance, size, drainage, swelling, pain, and status of drains or tubes.
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Unit 5
Sterility& sterilization
Introduction
Nurses are directly involved in providing a biologically safe
environment. Microorganisms exist everywhere: in water, in soil, and on
body surfaces such as the skin, intestinal tract, and other areas open to
outside (e.g., mouth, upper respiratory tract, vagina, and lower urinary
tract).
An infection is an invasion of body tissue by microorganisms and their
proliferation there. Such a microorganism is called an infectious agent. If
the microorganism produces no clinical evidence of disease, the infection is
called asymptomatic or sub-clinical.
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Some sub-clinical infections can cause significant damage, for example,
cytomegalovirus (CMV) infection in a pregnant woman can lead to
significant disease in the fetal. A detectable alteration in normal tissue
function, however is called disease.
Microorganisms vary in their virulence (i.e., their ability to produce
disease). Microorganisms also vary in the severity of the disease they
produce and their degree of communicability.
If the infectious agent can be transmitted to an individual by direct or
indirect contact, through a vector or airborne infection, the resulting
condition is called a communicable disease.
Asepsis is the freedom from disease-causing microorganisms. To decrease
the possibility of transferring microorganisms from one place to another,
asepsis is used.
There are two basic types of asepsis: medical and surgical asepsis.
1. Medical asepsis: includes all practices intended to confine a specific
microorganism to a specific area, limiting the number, growth, and
transmission of microorganisms, in medical asepsis, objects are referred to
as clean, which means the absence of almost all microorganisms, or dirty
(soiled, contaminated, which means likely to have microorganisms, some of
which may be capable of causing infection.
2. Surgical asepsis or sterile technique, refers to those practices that keep
an area or object free of all microorganism, it includes practices that destroy
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all microorganisms and spores. Surgical asepsis is used for all procedures
involving the sterile areas of the body.
Sepsis is the state of infection and can take many forms, including septic
shock.
Types of microorganisms causing infections
Four major categories of microorganisms cause infection in
humans:
1. Bacteria can live and be transported through air, water, food, soil, body
tissues and fluids, and inanimate objects.
2. Viruses consist primarily of nucleic acid and therefore must enter living
cells in order to reproduce. Common virus families include the rhinovirus
(causes the common cold) hepatitis, herpes, and human immunodeficiency
virus.
3. Fungi include yeasts and molds. Candida albicans is a yeast considered to
be normal flora in the human vagina.
4. Parasites live on other living organisms. They include protozoa such as
the that causes malaria.
Types of infection
 BY AREA
a) Local – limited to a specific body part
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b) Systemic – microorganisms have spread
 BY LENGTH OF TIME
a) Acute – appears suddenly/lasts short
b) Chronic – appears slowly, over long periods of time, may last
months/years
 BY CULTURE
a) Bacteremia – a culture of person’s blood reveals microorganisms
b) Septicemia – when bacteremia has multiplied and spread in a person’s
blood circulation
Signs of Localized Infection
• Localized swelling
• Localized redness
• Pain or tenderness with palpation or movement
• Palpable heat in the infected area
• Loss of function of the body part affected, depending on the site and
extent of involvement
• Fever
• Increased pulse and respiratory rate if the fever high
• Malaise and loss of energy
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• Anorexia and, in some situations, nausea and vomiting
• Enlargement and tenderness of lymph nodes that drain the area of
infection
Signs of Infection
• Laboratory data
• Elevated WBC count
• Increase in specific WBC types
• Elevated ESR
• Cultures of urine, blood, sputum, or other drainage
Risks for Nosocomial Infections
• Diagnostic or therapeutic procedures
– Iatrogenic infections
• Compromised host
• Insufficient hand hygiene
Factors Influencing Microorganism’s Capability to Produce Infection
• Number of microorganisms present
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• Virulence and potency of the microorganisms (pathogenicity)
• Ability to enter the body
• Susceptibility of the host
• Ability to live in the host’s body
Anatomic
and
Physiologic
Barriers Defend Against Infection
• Intact skin and mucous membranes
• Moist mucous membranes and cilia of the nasal passages
• Alveolar macrophages
• Tears
• High acidity of the stomach
• Resident flora of the large intestine
• Peristalsis
• Low pH of the vagina
• Urine flow through the urethra
Nosocomial infections
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Nosocomial infections are classified as infections that are associated
with the delivery of health care services in a health care facility(hospital
acquired infection). Nosocomial infections can either develop during a
client's stay in a facility or manifest after discharge.
The incidence of nosocomial infections is significant. Major sites for
these infections are the respiratory and urinary tracts, the bloodstream, and
wounds.
Factors that contribute to nosocomial infection risks are invasive
procedures, medical therapies, the existence of a large number of
susceptible persons, inappropriate use of antibiotics, and insufficient
hand washing after client contact and after contact with body
substances.
Chain of infection
Six links make up the chain of infection: the etiologic agent, or
microorganisms; the place where the organism naturally reservoir; a portal
of exit from reservoir; a method of transmission; a portal of entry into a host;
and susceptibility of the host.
1. Etiologic agent
The extent to which any microorganism is capable of producing an
infectious process depends on the number of microorganisms present.
2. Reservoir
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There are many reservoirs, or sources of microorganisms, common
sources are other humans, the client's, plants, animals, or general
environment.
3. Portal of exit from reservoir
Before an infection can establish itself in a host, the microorganisms
must leave the reservoir.
4. Method of transmission
there are three mechanisms
1. Direct transmission involves immediate and direct transfer of
microorganisms from person to person through touching, biting, kissing, or
sexual intercourse. Droplet spread is also a form of direct transmission.
2. Indirect transmission material objects, such as toys, soiled clothes,
cooking or eating and surgical instruments, or dressing, water, food, blood,
serum, and plasma. Animal or flying.
3. Airborntransmission may involve droplets or dust.
5. Portal of entry
Before a person can become infected, microorganisms must enter the
body. The skin is a barrier to infectious agents; however, any break in the
skin can readily serve as a portal of entry.
6. Susceptible Host
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A susceptible host is any person who is at risk for infection. A
compromised host is a person at "increased risk"

Practicing Homosexual/Bisexual
 Intravenous Drug Users
 Multiple Blood Transfusion
 HIV+ Persons/Immunocompromised
 Multiple Sexual Partners
 High-Risk Behaviors
 Very Young And Very Old
 Increased Length Of Stay
 Cancer Patients/Immunosuppressed
 Persons Under Stress
 Malnutrition
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1
Etiologic agent
(microorgnanisms)
6
2
Susceptible host
Reservoir
(source)
Chain of Infection
5
3
Portal of entry to
the susceptible
host
Portal of exit from
reservoir
4
Method of
transmission
Breaking the Chain of Infection
• Etiologic agent
– Correctly cleaning, disinfecting or sterilizing articles before use
– Educating clients and support persons about appropriate
methods to clean, disinfect, and sterilize article
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• Reservoir (source)
– Changing dressings and bandages when soiled or wet
– Appropriate skin and oral hygiene
– Disposing of damp, soiled linens appropriately
– Disposing of feces and urine in appropriate receptacles
– Ensuring that all fluid containers are covered or capped
– Emptying suction and drainage bottles at end of each shift or
before full or according to agency policy
• Portal of exit
– Avoiding talking, coughing, or sneezing over open wounds or
sterile fields
– Covering the mouth and nose when coughing or sneezing
• Method of transmission
– Proper hand hygiene
– Instructing clients and support persons to perform hand hygiene
before handling food, eating, after eliminating and after
touching infectious material
– Wearing gloves when handling secretions and excretions
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– Wearing gowns if there is danger of soiling clothing with body
substances
– Placing discarded soiled materials in moisture-proof refuse bags
– Holding used bedpans steadily to prevent spillage
– Disposing of urine and feces in appropriate receptacles
– Initiating and implementing aseptic precautions for all clients
– Wearing masks and eye protection when in close contact with
clients who have infections transmitted by droplets from the
respiratory tract
– Wearing masks and eye protection when sprays of body fluid
are possible
• Portal of entry
– Using sterile technique for invasive procedures, when exposing
open wounds or handling dressings
– Placing used disposable needles and syringes in punctureresistant containers for disposal
– Providing all clients with own personal care items
• Susceptible host
– Maintaining the integrity of the client’s skin and mucous
membranes
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– Ensuring that the client receives a balanced diet
– Educating the public about the importance of immunizations
Category-specific Isolation Precautions
• Strict isolation
• Contact isolation
• Respiratory isolation
• Tuberculosis isolation
• Enteric precautions
• Drainage/secretions precautions
• Blood/body fluid precautions
Transmission-Based Precautions
Category
Private Room
Contact
If
Gowns
possible; Required If
precautions cohort
available
Required
Dr. Abdul-Monim Batiha
Gloves
if
not
Masks
anticipate Not required
contact with soiled
items;
patient
is
incontinent;
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diarrhea,
ileostomy,
colostomy,
wound drainage
Droplet
If
possible; Not
precautions cohort or
Not required
required
Required
when within
maintain
3 feet
separation of
3 feet
Airborne
Required.
Not
precautions Negative air
pressure,
required
6–12
air
changes
Not required
N95
respirator
required
for known or
per
suspected
hour, keep door
tuberculosis
closed, discharge
and measles
air
or varicella if
outdoors
or
not immune
HEPA filter
Disease-specific Isolation Precautions
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• Outline practices for control of specific diseases
– Use of private rooms with special ventilation
– Cohorting(grouping) clients infected with the same organism
– Gowning to prevent gross soilage of clothes
Universal Precautions (UP)
• Used with all clients
• Decrease the risk of transmitting unidentified pathogens
• Obstruct the spread of bloodborne pathogens (hepatitis B and C
viruses and HIV)
• Used in conjunction with disease-specific or category-specific
precautions
Body Substance Isolation (BSI)
• Employs generic infection control precautions for all clients
• Body substances include:
– Blood
– Urine
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– Feces
– Wound drainage
– Oral secretions
– Any other body product or tissue
Standard Precautions
• Used in the care of all hospitalized persons regardless of their
diagnosis or possible infection status
• Apply to
– Blood
– All body fluids, secretions, and excretions except sweat
(whether or not blood is present or visible)
– Nonintact skin and mucous membranes
• Combine the major features of UP and BSI
Transmission-based Precautions
• Used in addition to standard precautions
• For known or suspected infections that are spread in one of three
ways:
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– Airborne
– Droplet
– Contact
• May be used alone or in combination but always in addition to
standard precautions
Bloodborne Pathogen Exposure
• Report the incident immediately (incident report)
• Complete injury report
• Seek appropriate evaluation and follow-up. This includes:
1. Identification and documentation of the source individual when
feasible and legal
2. Testing of the source for hepatitis B, C and HIV when feasible and
consent is given
3. Making results of the test available to the source individual’s health
care provider
4. Testing of blood exposed nurse (with consent) for hepatitis B, C, and
HIV – please check these to match style used in book – fairly certain
it should be caped antibodies
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5. Postexposure prophylaxis if medically indicated
6. Medical and psychologic counseling
For Puncture/Laceration
• Encourage bleeding
• Wash/clean the area with soap and water
• Initiate first aid and seek treatment if indicated
• Mucous membrane exposure (eyes, nose, mouth):
-Flush with saline or water flush for 5 to 10 minutes
Postexposure Protocol (PEP) for Hepatitis B
• Anti-HBs testing 1 to 2 months after last vaccine dose
• HBIG and/or hepatitis B vaccine within 1 to 7 days following
exposure for nonimmune workers
Postexposure Protocol (PEP) for Hepatitis C
There is currently no vaccine against the virus no post exposure prophylaxis.
Prevention remains the primary goal.
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Human body area reservoirs, common infectious microorganisms, and portal of exit
common
Body area
Respiratory tract
infectious
microorganisms
Parainfluenza virus
Mycobacterium tuberculosis
Gastrointestinal
tract
Hepatitis a virus,
Salmonella species
Portal of exit
Nose or mouth through sneezing
coughing, breathing, or talking.
Mouth: saliva, vomitus, anus: feces,
ostomies
Urinary tract
Escherichia coli
Urethral meatus and urinary diversion
Reproductive tract
Neisseria gonorrhoeae
Vagina: vaginal discharge; urinary
Herpes simplex virus type2
Blood
Hepatitis B virus, HIV
Staphylococcus
meatus:semen, urine
Open wound, needle puncture site,
any disruption of intact skin or
mucous membrane surface
Tissue
Staphylococcus
Drainage from cut or wound
Streptococus
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Factors Increasing Susceptibility to Infection
1. Age influence the risk of infection. Newborns and older adults have
reduced defenses against infection.
2. Heredity influences the development of infection in that some people have
a genetic susceptibility to certain infections.
3. The nature, number, and duration of physical and emotional stressors can
influence susceptibility to infection. Stressors elevate blood cortisone.
Prolonged elevation of blood cortisone decrease anti-inflammatory
responses depletes energy stores, lead to a state of exhaustion, and decrease
resistance to infection. For example: a person recovering from a major
operation or injury is more likely to develop an infection than healthy
person.
4. Resistance to infection depends on adequate nutritional status.
5. Some medical therapies predispose a person to infection. For example,
radiation treatments for cancer, some diagnostic procedures may also
predispose the client to an infection.
6. Certain medication also increase susceptibility to infection. Anticancer
medications may depress bone marrow function, resulting inadequate
production of white blood cells, anti-inflammatory and antibiotics
medications.
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WHO IS AT RISK FOR INFECTION?
 THE HOSPITAL STAFF/SERVICE PROVIDERS
They are exposed to potentially infectious blood and body fluids on a daily
basis
 CLIENTS IN THE HOSPITAL
Service providers who do not wash hands in between clients and procedures.
NOSOCOMIAL INFECTION: Hospital-acquired infection
IATROGENIC INFECTION: Direct result of procedures or therapeutic
treatments or diagnostic examinations
 THE COMMUNITY
Unsanitary waste disposal, improper disposal of medical wastes such as
contaminated sharps, dressings
STOPPING TRANSFER OF INFECTION
1) handwashing – the singlemost effective control measure to control
infections
2) asepsis– medical asepsis versus surgical asepsis
3) wearing of gloves
4) proper handling and disposal of sharps
5) proper instrument processing
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6) proper waste disposal
Cleaning, Disinfecting, and Sterilizing
The first links in the chain of infection, the etiologic agent and the
reservoir, are interrupted by the use of antiseptics (agents that inhibit the
growth of some microorganisms) and disinfectants (agents that destroy
pathogens other than spores) and by sterilization.
Cleaning
Cleanliness inhibits the growth of microorganisms. When cleaning
visibly soiled objects, nurses must always wear gloves to avoid direct
contact with infections microorganisms. Most objects used in the care of
clients, whether forceps or draw sheets, can be cleaned by rinsing them in
cold water to remove any organic material, washing them with hot soapy
water, then rinsing them again to remove the soap.
 Disinfectants are antimicrobial agents that are applied to non-living
objects to destroy microorganisms, the process of which is known as
disinfection. Sanitizers are high level disinfectants that kill over
99.9% of a target microorganism in applicable situations. Very few
disinfectants and sanitizers can sterilize.
 Antiseptics are chemical agents used on living objects to reduce the
number of microorganisms on skin and mucous membranes without
causing tissue damage. They can prevent the growth and development
of some microorganisms.
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 Used for: surgical scrub, skin prep of clients, handwashing in high
risk cases of newborn, immunocompromised clients
 Antiseptics:
Iodophors
(betadine),
Iodine(povidine),
Sodium
hypochlorite, Hydrogen peroxide 3%, alcohol, ethyl or isopropyl
alcohol, chlorhexedine
 Antiseptics do not have the same killing power of disinfectants
 Disinfectants:
1) Glutaraldehyde (Cidex) – irritating, used for sterilization of
medical/surgical instruments; Formaldehyde – acqueous solution used
for embalming(preserving)
2) Halogens (Chlorine, Sodium hypo) – strong oxidizing agents used for
decontamination, high-level disinfection
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 Prevention Contamination of Antiseptics:
 Use sterile solution as diluent.
 Pour out antiseptics into sterile containers.
 Open caps and put on a surface with sterile side up.
 Never leave cotton balls or gauze soaked in an antiseptic solution.
 Never dip cotton or gauze into antiseptics. Instead, pour the antiseptic
on the cotton or gauze.
 Clean the area on which solutions are prepared.
 Prevention Contamination of Antiseptics:
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Properties of Common Antiseptics
• IODOPHORS (Betadine)
- Contain iodine in noncomplex form; non-irritating, nontoxic
- Effective against a range of microorganisms
- USAGE: For surgical scrub and client prep; effective 1-2 minutes
after application; use full strength
- ADVANTAGES: Less irritating than iodine
- DISADVANTAGES: Effectiveness is reduced by presence of blood
and other organic materials
• IODINE; TINCTURE OF IODINE
- Effective against a range of microorganisms
- USAGE: For skin decontamination, wound packing and irrigation
iodine must be allowed to dry and then removed from the skin using
alcohol
- ADVANTAGES: Fast acting
- DISADVANTAGES: Too irritating for surgical scrub or for mucous
membranes. Effectiveness is reduced by presence of blood and other
organic materials
• ALCOHOL (60%-90%)
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- Effective against a range of microorganisms
- USAGE: skin prep before injection, Cannot be used when skin is
visibly dirty; wash the area first; must dry completely to be effective
- ADVANTAGES: Kills microorganisms rapidly. Most effective in
reducing microorganisms.
- DISADVANTAGES: Has drying effect on skin. Cannot be used on
mucous membranes. Effectiveness is reduced by presence of blood
and other organic materials
-Hydrogen peroxide 3% (H2O2) kill decomposes necrotic tissue and used
for wound irrigation, cleaning of pus and necrotic tissue.
PROPER HANDLING AND DISPOSAL OF SHARPS
 Avoid recapping the needle
 Do not bend, cut or break needles
 Dispose of needles and sharps in a puncture-resistant container
 Wear utility gloves when disposing of sharps container
PROPER INSTRUMENT PROCESSING
1. DECONTAMINATION – makes items easier to clean by softening
blood, body fluids, tissues; makes items safer to clean
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 Chlorine:
- Disinfectant; powerful killer of microorganisms
- Deodorizes; not poisonous in its concentration
- Leaves no poisonous residue
- Colorless, easy to handle, economical to use
- Acceptable household/hospital disinfectant is 0.5% chlorine solution
2. CLEANING:
 Refers to scrubbing with a brush, detergent and water
 Removes organic material, dirt and foreign matter that can interfere
with sterilization.
 Reduces the number of microorganisms
 Removes contaminants in joints, grooves and teeth of items
3. STERILIZATION:
 Ensures freedom from all microorganisms
 For surgical instruments, needles, that come in contact with
bloodstream or tissues
 3 methods
a) Steam sterilization - “autoclaving”, or moist heat under pressure
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b) Dry heat – high heat for prolonged period of time
c) Chemical – for heat-sensitive items (Cidex)
HIGH-LEVEL DISINFECTION
 Eliminates microorganisms but does not kill endospores which gas
gangrene, tetanus
 Suitable for items that come in contact with broken skin or intact
mucous membrane
 3 methods:
a) Boiling – longer than 20 minutes
b) Chemical – for heat-sensitive items (Cidex, Chlorine)
c) Steam – best for gloves
5- USED OR STORED
 If items are not properly stored, all efforts will have been wasted,
items may be contaminated
 Always store instruments dry
 Do not store them soaked in antiseptic or disinfectant solutions
6. PROPER WASTE DISPOSAL
 General Housekeeping Guidelines:
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 Wear thick gloves when cleaning
 Reduce spread of dust and microorganisms by damp(wet) mop or
cloth for walls, floors and surfaces
 Scrubbing is the most effective way to remove dirt and
microorganisms
 Wash surfaces from top to bottom so that debris falls in the floor is
cleaned up last
 Change cleaning solutions whenever they appear dirty
 Cleaning up spills(drops):
 Clean up immediately any potentially infectious fluids
 Always wear gloves when cleaning spills
 If spill is small, clean with cloth that’s saturated with disinfectant
 If spill is large, flood with a disinfectant, mop it and then scrub the
area with a disinfectant cleaning solution
 Change cleaning solutions whenever they appear dirty
 Do not put a cloth over a spill for cleaning up later
 Three kinds of waste in the community:
1. General waste – poses no risk of injury or infection (bottles, boxes,
food-related trash, plastic containers..)
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2. Medical waste – generated in the diagnosis, tx, or immunization
3. Hazardous chemical waste – those that are potentially toxic or
poisonous, and radioactive compounds
 Three kinds of waste in the hospital:
1. Biodegradable – any organic wastes that are perishable(subject to
decay) and are rotten(fragile from use)
2. Non-biodegradable – those that are not perishable like plastics,
bottles, packaging materials
3. Infectious – those that have come in contact with blood and body
fluids (sponges, needles, sharps etc.)
Sterilizing
Sterilization is a process that destroys all microorganisms, including
spores and viruses. Four commonly used methods of sterilization are:
1. Moist heat: for sterilizing, moist heat (steam) can be employed in two
ways: as steam under pressure attains temperatures higher than the boiling
point. Autoclaves supply steam under pressure of 121 to 123C.
Free steam 100C is used to sterilize objects that would be destroyed at the
higher temperature and pressure of autoclave.
Contamination can occur at latent time, so packaging should be checked for
integrity. Because the object is considered sterile only for specified period,
always check the expired date.
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2. Gas: Ethylene oxide gas destroys microorganisms by interfering with
their metabolic processes. Its advantages are good penetration and
effectiveness for heat-sensitive items. Its major disadvantage is its toxicity to
human.
3. Boiling water: this is the most practical and inexpensive method for
sterilizing in the home. The water temperature rises no higher than 100C.
Boiling a minimum 0f 15 minutes is advised for disinfection of articles in
the home.
Boiling water is not an effective sterilization measure as some viruses and
spores can survive boiling water. Objects that have been boiled in water for
15 to 20 minutes at 121°C (249.8°F) are considered clean but not sterilized
However, boiling water is still the best and most common sterilization
measure used in the home. For example, boiling baby bottles and nipples
makes them safe for use.
4. Radiation: both ionizing and nonionizing radiation can be used for
disinfection and sterilization. Ultraviolet light, a type of non-ionizing
radiation, can be used for disinfection. Ionizing radiation is used effectively
in industry to sterilize foods, drugs, and other items that are sensitive to heat.
Its main advantage is that it is effective for items difficult to sterilize, its
chief disadvantage is that the equipment is very expensive.
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Sterile Technique:
An object is sterile only when it is free of all microorganisms.
The basic principles of surgical asepsis:
1. All objects used in a sterile field must be sterile.
2. Sterile objects become unsterile when touched by un-sterile objects.
3. Sterile items that are out of vision or below the waist level of the nurse are
considered unsterile.
4. Sterile objects can become unsterile by prolonged exposure to airborne
microorganisms.
5. Fluids flow in the direction of gravity.
6. Moisture that passes through a sterile object draws microorganisms from
un-sterile surfaces above or below to the sterile surface by capillary action.
7. The edges of a sterile field are considered un-sterile.
8. The skin cannot be sterilized and is un-sterile.
9. Carefulness, alertness, and honesty are essential qualities in maintaining
surgical asepsis.
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