RLE MODULE 1F:
Interventions for Common
Signs and Symptoms
DEFINITION OF TERMS; Related to Signs and Symptoms
● Intervention - act of interfering with a condition or process's result or
course, to prevent harm or improve functioning.
● Sign - any objective signs that is directly observed by a physician or a nurse
and can be measured with an equipment; pulse rate, body temperature,
oxygen level, vital signs, blood pressure, heart rate, respiratory rate
QUESTION: Would pain be under the category of sign since there
are scales and charts used to measure a person’s pain level?
■ If she says 8/10 and there are observable actions then it
would be sign
■ It should also be detailed and evidential for it to be considered
as a sign
● Symptom – subjective, only patients can verify; chest pain, headache, loss
of taste or smell, fatigue
● Syndrome - a group of signs and symptoms linked to any afflictive process
that collectively characterize the disease's overall image.
○ Group of traits or conditions that occur together and characterize a
recognizable disease
● Fever - increase in body temperature higher than the normal body
temperature 98.6 F. or (37 C).
○ 99 F (37.2 C) or above – armpit
○ 100 F (37.8 C) or above – oral temperature
○ 100.4 F (38 C) or above – rectal, ear, temporal artery
CHECK THE BOOK FOR THE NORMAL BODY TEMP RANGE
● Tepid Sponge Bath - therapeutic bath by washing all around the body
using a sponge to dilate superficial blood vessels, thus releasing heat
and lowering down body temperature.
● Cough - this is the body’s response to irritants (mucus, dust, smoke) in
your airways.
● Chest Physiotherapy - it is an airway clearance technique to empty the
lungs that includes the use of:
○ percussion (clapping),
○ vibration,
○ postural drainage – expel mucus or airway clearance with the use
of gravity
○ Best determinant is body weight
● Rehydration - the process of replenishing the body's fluids and tissues
with lost water.
● Oral Rehydration Solution (ORESOL) - an aqueous mixture of glucose
and electrolytes having rehydrating properties and dehydration prevention
properties: such as
■ sodium, potassium, chloride, magnesium, and phosphorus.
● Oral Rehydration Therapy - consists of providing a dehydrated patient a
drink that is a combination of water, glucose, and salts to restore the body's
normal amounts of fluids, carbohydrates, and electrolytes.
IMPORTANCE:
● Chest tapping “thoracentesis” – excess fluids in the pleural space
between lungs and chest wall is removed by tapping the areas
● Expectorant - a type of cough medicine used to assist removal of mucus
(phlegm) from your airways.
● Diarrhea - refers to a more-frequent bowel movements with loose and
watery fecal characteristics; if it happens at least bathroom call for just a
day
● Dehydration - body lacks sufficient water and other fluids to perform its
regular functions because you expend or lose more fluid than you consume.
❖ Importance of Tepid Sponge Bath:
• reduces fever by dilating superficial blood vessels, thus releasing heat and
lowering body temperature.
o effectiveness is just equivalent to taking a Paracetamol, study shows
that tepid sponge bath lowers the temperature faster within 30 and
even more effective at lowering body temperature when combined.
• lower systemic temperature when routine fever treatments fail, particularly
for infants and children, whose temperatures tend to rise very high, very
quickly.
• What type of water will you be using for tepid sponge bath?
o Utilize lukewarm water
o Cold water shouldn’t be used because there will be an abrupt change
in the client’s temperature
❖ Importance of Chest tapping:
• get rid of extra mucus in his or her lungs. This is important because too
much mucus can block the airways in the lungs. If the airways are blocked,
the air cannot move in and out like it should.
• essential in the airway clearance of acute and chronic respiratory disorders
with retained airway secretions.
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improve and maintain the well-being of the patients within the limitations
imposed by the impaired lung function.
Regular Chest physiotherapy plays a significant role in reducing the
morbidity in children with chronic lung diseases like cystic fibrosis.
❖ Importance of ORESOL (oral rehydration solution) preparation:
• replenish the body’s fluid levels.
o treat moderate dehydration due to diarrhea, vomiting, or other
conditions.
▪ To assess baby’s dehydration (baby: check the fontanelle if
less than 12 months, if there is a depression → dehydrated)
• ORESOL contains specific amounts of glucose and electrolytes. The
electrolytes are potassium and sodium. That is why such solutions are given
to babies suffering from diarrhea. The use of ORESOL is not only limited to
babies as elders are also prescribed it for staying hydrated.
Intermittent
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Remittent
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DIFFERENT TYPES OF FEVER, COUGH, DIARRHEA
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TYPES OF FEVER
Research different types of fever not limited to this; continuous, hectic
temperature rise lasts for a short time before returning to
normal.
Causes: focal bacterial infections (canals; urinary or biliary
ducts or the colon) and infections caused by foreign
material.
Temperature remains higher than usual throughout the
day and swings by more than 1 degree celsius in 24
hours, indicating infective endocarditis.
Causes: viral upper respiratory tract, legionella, and
mycoplasma infections.
Relapsing
Constant
Temperature returns to normal for a few days before rising
again.
Causes: borrelia bacteria species, Tick-borne
relapsing fever (TBRF) (ornithodoros tick)
The temperature remains above normal throughout the day
and fluctuates by no more than 1 degree celsius in 24
hours.
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TYPES OF COUGHS
RESEARCH DIFF TYPES OF COUGHS; Paroxysmal, croup and others
Productive
Non-productive
- when it pulls up or generates - produces no mucus or other
mucus or any type of fluid,
discharges.
including blood, from the lungs or - dry cough
nasal sinuses.
- Many people describe the irritability
- assists in the removal of mucus
as “tickling” or “scratchy.”
(sputum) and foreign particles from - Causes: throat irritation
the airways.
- Postnasal drainage occurs when a
cold or allergy causes mucus to leak
down the back of the throat.
- Causes: Bronchitis, pneumonia, or
chronic obstructive pulmonary
diseases (COPD).
TYPES OF DIARRHEAS
Acute
- three or more loose stools per day
that lasts no more than 14 days.
- Causes:
Viruses
(viral
gastroenteritis
- Diarrhea is frequently self-limiting.
- sometimes early use of oral
rehydration therapy is the best
option for treating acute diarrhea.
Chronic
- lasts more than 14 days.
- fatty or malabsorption diarrhea,
inflammatory diarrhea, or watery
diarrhea.
- Cause: Inflammatory bowel illness
(IBD)
❖ Types of Fever
Interventions:
● To assess causative/ contributing factor
- Identifying underlying cause.
- Note chronological and developmental age of client.
● To evaluate effects/ degree of fever
- Monitor core temperature by appropriate route (e.g., tympanic,
rectal). Note the presence of temperature elevation (>98.6 degrees
fahrenheit [37 degree celsius]) or fever (100.4 degree fahrenheit [38
degree celsius]).
- Assess whether body temperature reflects heat stroke.
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Assess neurological responses, noting the level of consciousness and
orientation, reaction to stimuli, reaction of pupils, and presence of
posturing or seizures.
- Monitor blood pressure and invasive hemodynamic parameters if
available (e.g., mean arterial pressure [MAP], central pulmonary
capillary wedge pressure [PCWP]).
- Monitor heart rate and rhythm.
- Monitor respirations.
- Auscultate breath sounds, noting adventitious sounds such as
crackles (rales).
- Monitor and record all sources of fluid loss such as urine and
diarrhea, wounds, fistulas, and insensible losses.
- Note the presence or absence of sweating as the body attempts to
increase heat loss by evaporation, conduction, and diffusion.
- Monitor laboratory studies, such as arterial blood gas levels (ABGs),
electrolytes, and cardiac and liver enzymes; glucose; urinalysis; and
coagulation profile.
● To assist with measures to reduce body temperature/ restore
normal body/organ function
- Administer antipyretics, orally or rectally (e.g., ibuprofen,
acetaminophen), as ordered. Refrain from use of aspirin products in
children or individuals with a clotting disorder or receiving
anticoagulant therapy.
- Promote surface cooling by means of undressing; cool environment
and/or fans; cool, tepid sponge baths or immersion; or local ice
packs, especially in groin and axilla. In pediatric clients, tepid water
is preferred.
- Monitor used of hypothermia blanket and wrap extremities with bath
towels. Turn off hypothermia blanket when core temperature is
within 1 to 3 degrees of desired temperature.
- Administer medications (e.g., chlorpromazine or diazepam), as
ordered.
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Assist with internal cooling methods to treat malignant hyperthermia.
Promote client safety (e.g., maintain patent airway; padded side
rails; quiet environmental; mouth chare for dry mucous membranes;
skin protection from cold, when hypothermia blanket is used;
observation of equipment safety measures).
- Provide supplemental oxygen.
- Administer medications, as indicated such as antibiotics, dantrolene,
or beta-adrenergic blockers.
- Administer replacement fluids and electrolytes.
- Maintain bedrest.
- Provide high-calorie diet, enteral nutrition, or parenteral nutrition.
● To promote wellness (teaching/ discharge considerations)
- Instruct the parents in how to measure the child’s temperature, at
what body temperature to give antipyretic medications, and what
symptoms to report to the physician.
- Review specific risk factor or cause, such as (1) underlying conditions
(hyperthyroidism, dehydration, neurological diseases, nausea,
vomiting, sepsis); (2) use of certain medications (diuretics, blood
pressure medications, alcohol or other drugs [cocaine,
amphetamines]); (3) environmental factors (exercise or labor in hot
environment, lack of air conditioning, lack of acclimatization); (4)
reaction to anesthesia (malignant hyperthermia); or (5) other risk
factors (salt or water depletion, elderly living alone).
- Identify those factors that the client can control (if any), such as (1)
treating underlying disease process (e.g., thyroid control
medication), (2) protecting oneself from excessive exposure to
environmental heat (e.g., proper clothing, restriction of activity,
scheduling outings during cooler part of day, use of fans/airconditioning where possible), and (3) understanding family traits
(e.g., malignant hyperthermia reaction to anesthesia is often
familial).
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Instruct families/caregivers (of young children, persons who are
outdoors in very hot climate, elderly living alone) in the dangers of
heat exhaustion and heatstroke and ways to manage hot
environments. Caution parents to avoid leaving young children in an
unattended car, emphasizing the extreme hazard to the child in a
very short period of time.
Discuss importance of adequate fl uid intake at all times and ways to
improve hydration status when ill or when under stress (e.g.,
exercise, hot environment)
Review signs/symptoms of hyperthermia (e.g., fl ushed skin,
increased body temperature, increased respiratory and heart rate,
fainting, loss of consciousness, seizures).
Recommended avoidance of hot tubs and sauna, as appropriate.
Identify community resources, especially for elderly clients, to
address specific needs.
❖ Types of Cough
Interventions:
● To maintain adequate, patent airway:
- Identify client populations at risk.
- Assess level of consciousness/ cognition and ability to protect own
airway.
- Monitor respirations and breath sounds, noting rate and sounds
(e.g., tachypnea, stridor, crackles, or wheezes).
- Evaluate client’s cough/ gag reflex, amount and type of secretions,
and swallowing ability.
- Position head appropriately for age and condition.
- Suction nose, mouth, and trachea prn using correct-size catheter and
suction timing for child or adult.
- Insert oral airway (using correct size for adult or child) when needed.
- Elevate head of bed, encourage early ambulation, or change client’s
position every 2 hr.
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Exercise diligence in providing oral hygiene and keeping oral mucosa
hydrated.
- Monitor infant/ child for feeding intolerance, abdominal distension,
and emotional stressors.
- Assist with appropriate testing (e.g., pulmonary function or sleep
studies).
- Instruct in/ review postoperative breathing exercises, effective
coughing, and use of adjunct devices (e.g., intermittent positive
pressure breathing or incentive spirometer) in preoperative teaching.
- Assist with procedures (e.g., dust, feather pillows, or smoke)
according to individual situation.
● To mobilize secretions:
- Mobilize the client as soon as possible.
- Encourage deep-breathing and coughing exercises or splint chest/
incision.
- Administer analgesics.
- Administer medications (e.gexpectorants, anti-inflammatory agents,
bronchodilators, and mucolytic agents), as indicated.
- Increase fluid intake to at least 2000 mL/day within cardiac tolerance
(may require IV in acutely ill, hospitalized client). Encourage/ provide
warm versus cold liquids as appropriate. Provide supplemental
humidification, if needed (ultrasonic nebulizer or room humidifier).
Monitor for signs/symptoms of congestive heart failure (crackles,
edema, or weight gain) when the client is at risk.
- Perform or assist the client in learning airway clearance techniques,
such as postural drainage and percussion (chest physical therapy
[CPT]), fluter devices, high-frequency chest compression with an
inflatable vest, intrapulmonary percussive ventilation (IPV), and
active cycle breathing technique (ACBT). (Refer to NDs ineffective
Breathing Pattern; impaired Gas Exchange, impaired spontaneous
Ventilation.)
- Support reduction/cessation of smoking
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Position appropriately (e.g., head of bed elevated, side lying) and
discourage use of oil-based products around nose. (Refers to NDs
risk for Aspiration; impareid swallowing.)
● To assess changes, note complications:
- Auscultate breath sounds and assess air movements.
- Monitor vital signs, noting changes in blood pressure and heart rate.
- Observe for signs of respiratory distress (increased rate,
restlessness/ anxiety, or use of accessory muscles for breathing).
- Evaluate changes in sleep pattern, noting insomnia or daytime
somnolence. (Refer to NDs Insomnia, Sleep Deprivation.)
- Document response to drug therapy and/or development of adverse
side effects or interactions with antimicrobials, steroids,
expectorants, and bronchodilators.
- Observe for signs/symptoms of infection (e.g., increased dyspnea
with onset of fever or change in sputum color, amount, or character)
- Obtain sputum specimen, preferably before antimicrobial therapy is
initiated.
- Monitor/ document serial chest x-rays, arterial blood gasses or pulse
oximetry readings.
● To promote wellness (Teaching/ Discharge Considerations):
- Assess client’s/ significant other’s (SO) knowledge of contributing
causes, treatment plan, specific medications, and therapeutic
procedures.
- Provide information about the necessity of raising and expectorating
secretions versus swallowing them.
- Demonstrate/ assist
client/SO in performing specific airway
clearance techniques (e.g., forced expiratory breathing [also called
huffing] or respiratory muscle strength training, chest percussion, or
use of a best), as indicated.
- Instruct client/SO/caregiver in use of inhalers and other respiratory
drugs. Include expected effects and information regarding possible
side effects and interactions of respiratory drugs with other
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medications, over-the-counter medications, and herbals. Discuss
symptoms requiring medical follow-up.
Encourage/provide opportunities for rest; limit activities to level of
respiratory tolerance.
Urge reduction or cessation of smoking.
Refer to appropriate support groups (e.g., stop smoking clinic, COPD
exercise group, weight reduction, the American Lung Association, the
Cystic Fibrosis Foundation, or the Muscular Dystrophy Association).
Determine that the client has equipment and is informed in the use
of nocturnal continuous positive airway pressure (CPAP). (Refer to
NDs Insomnia, Sleep Deprivation.)
❖ Types of Diarrhea
Interventions:
● To assess causative factors/ etiology.
- Ascertain onset and pattern of diarrhea, noting whether acute or
chronic.
- Obtain history and observe stools for volume, frequency (e.g., more
than normal number of stools per day), characteristics (e.g., travel,
recent antibiotic use, day care center attendance) related to
occurrence of diarrhea.
- Note the client's age.
- Determine if incontinence is present. (Refer to ND bowel
Incontinence.)
- Note reports of abdominal or rectal pain associated with episodes.
- Auscultate abdomen.
- Observe for the presence of associated factors, such as fever or
chills, abdominal pain and cramping, bloody stools, emotional upset,
physical exertion, and so fort.
- Evaluate diet history, noting food allergies or intolerances and food
and water safety issues, and not general nutritional intake and fluid
and electrolyte status.
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Review medications, noting side effects and possible interactions.
Determine recent exposure to different or foreign environments,
change in drinking water or food intake/ consumption of unsafe food,
swimming in untreated surface water, and similar illness of family
members/ others close to client.
- Note history of recent gastrointestinal surgery, concurrent or chronic
illness and treatment, food or dug allergies, and lactose intolerance.
- Review results of laboratory testing.
● To eliminate causative factors.
- Restrict solid food intake, as indicated.
- Provide for changes in dietary intake
- Limit caffeine and high-fiber foods; avoid milk and fruits, as
appropriate.
- Adjust strength or rate of enteral tube feedings; change formula, as
indicated.
- Assess for and remove fecal impaction, especially in an elrdly client.
(Refer to NDs Constipation; bowel Incontinence.)
- Recommend change in drug therapy, as appropriate (e.g., choice of
antibiotic).
- Assist in treatment of underlying conditions (e.g., infections,
malabsorption syndrome, cancer) and complications of diarrhea.
- Promote use of relaxation techniques (e.g., progressive relaxation
exercise, visualization techniques)
● To maintain hydration/ electrolyte balance.
- Note reports of thirst, less frequent or absent urination, dry mouth
and skin, weakness, light-headedness, and headaches.
- Monitor total intake and output, including stool output as possible.
- Observe for or question parents about young child crying with no
tears, fever, decreased urination, or no wet diapers for 6 to 8 hr;
listlessness or irritability; sunken eyes; dry mouth and tongue; and
suspected or documented weight loss.
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Asses for the presence of postural hypotension, tachycardia, skin
hydration/ turgor, and condition of mucous membranes.
- Weigh infant’s diapers
- Review laboratory studies for abnormalities.
- Administer antidiarrheal medications, as indicated.
- Encourage oral intake of fluids containing electrolytes, such as
Gatorade, Pedialyte, Infalyte and Smart Water, as appropriate.
- Administer IV fluids, electrolytes, enteral and parenteral fluids, as
indicated.
● To maintain skin integrity.
- Assist, as needed, with pericare after each bowel movement.
- Provide prompt diaper/ incontinence brief change and gentle
cleansing.
- Use appropriate padding and pressure-reducing devices, where
indicated.
- Apply lotion or ointment as skin barrier, as needed.
- Provide wrinkle-free dry linen, as necessary.
- Refer to NDs impaired Skin Integrity, and risk for impaired Skin
Integrity.
● To promote return to normal bowel functioning
- Increased oral fluid intake and return to normal diet, as tolerated.
- Encourage intake of nonirritating liquids.
- Discuss possible change in infant formula.
- Recommend products such as natural fiber, plain natural yogurt, and
Lactinex.
- Administer medications, as ordered.
- Provide privacy during defecation and psychological support, as
necessary.
● To promote wellness (Teaching/ Discharge Considerations)
- Review causative factors and appropriate interventions.
- Discuss individual stress factors and coping behaviors.
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Review food preparation, emphasizing adequate cooking time and
proper refrigeration or storage.
Emphasize importance of hand hygiene
Discuss the possibility of dehydration and the importance of proper
fluid replacement.
Suggest the use of incontinence pads (depending on the severity of
the problem).
SIGNS AND SYMPTOMS OF: fever, cough and diarrhea
Signs
Symptoms
Fever
● A temperature higher than:
● Body aches and headaches.
○ 100.4 °F
or 38°C ● Fatigue (tiredness)
(rectally)
● Loss of appetite
○ 99.5°F
or
37.5°C ● Intermittent or constant
(orally)
sweating.
○ 99.5°F
or
37.5°C ● Unwell
(measured under the
arm / in armpit)
● Increased pulse and heart rate
(When the temperature rose by
1 degree C, the heart rate
increased on the average by
8.5 beats per minute.)
● Increased BP
● Shivering, chills and shaking
● Flushed skin – warm to touch
Cough
● Presence of phlegm or sputum ● A feeling of liquid running
(for wet cough)
down the back of the throat
● Rarely, coughing up blood
(postnasal drip)
● Runny nose
● stuffy nose
● Wheezing
● Frequent throat clearing
● Hoarseness
of
voice
and sore throat
(observable)
● shortness of breath
● Heartburn or a sour taste
in the mouth.
Diarrhea ● Dry skin and sunken eyes due ● Abdominal cramps
to dehydration
● Abdominal pain
● Rapid and deep respiration
● Bloating
● Rapid pulse rate
● Fatigue
● Low Blood Pressure (BP)
● Nausea
● Vomiting
● Frequent, loose, watery stools
● Weight loss
QUESTION: cold skin or hot skin be considered a symptom since there’s no
temperature indicated?
• Cold skin or hot skin is considered a SIGN because it is observable and can
be verified
PRINCIPLES AND GUIDELINES of tepid sponge bath, chest tapping,
oresol preparation
Tepid Sponge Bath
● Anatomy and Physiology
- Knowing both anatomy and physiology is essential for delivering
tepid sponge baths because the nurse must note which bodily parts
need sponges.
● Microbiology
- Tepid sponge bath is done to eliminate pathogenic microorganisms.
To prevent the spread of bacteria, all objects that will be used for
the sponge bath should be well cleansed and washed.
● Psychology
- Tepid Sponge Bath promotes a state of well-being. It is effective in
relieving fever by reducing high temperature. It is also helpful in
alleviating pain and providing comfort and relaxation. The procedure
must be explained to the patient in order for him or her to mentally
prepare for the procedure, reducing anxiety and encouraging
cooperation.
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● Physics
- Tepid sponging is the application of water to the patient's skin
surface to promote dispersal of body heat when the body
temperature is 39.5°C and over. The procedure is based on the
principles of evaporation and conduction.
Chest Tapping
● Anatomy and Physiology
- As the procedure is carried out, the nurse should be aware of the
landmarks in relation to respiratory assessment, proper positioning,
or percussion of the client.
● Body Mechanics
- With conventional CPT, you get into various positions to drain the
excess mucus from the different lobes of your lungs. Each position
is specifically designed so that one of the five lobes of the lungs is
facing downward. The nurse must assist the client in assuming the
appropriate position. To avoid unintended injury, the nurse should
periodically check the client's position.
● Microbiology
- To avoid the transmission of microorganisms, all materials used for
chest tapping should be thoroughly cleaned and washed. Maintain
cleanliness throughout the procedure when handling the drained
pulmonary secretions.
● Psychology
- Chest tapping helps you access your body's energy and send signals
to the part of the brain that controls stress. They claim that
stimulating the meridian points through EFT tapping can reduce the
stress or negative emotion you feel from your issue, ultimately
restoring balance to your disrupted energy. The procedure must be
explained to the patient in order for him or her to mentally prepare
for the procedure, reducing anxiety and encouraging cooperation.
● Physics
- This enables gravity, power and pressure applied through percussion
or tapping, as well as vibration, to aid in the removal of bronchial
secretions from various lung segments.
● Chemistry
- It results in release of energizing chemicals such as epinephrine.
Oresol Preparation
● Anatomy and Physiology
- The body part - small intestine plays an important role in the
regulation of water and electrolyte balance between plasma and
intestinal lumen.
● Microbiology
- Oral rehydration therapy is used for treating the more serious
dehydration that is caused by viral gastroenteritis, also known
as stomach flu. This virus can cause a child to vomit repeatedly or
have prolonged diarrhea, which can result in dehydration. To avoid
the transmission of microorganisms, all materials used for chest
tapping should be thoroughly cleaned and washed. Maintain
cleanliness throughout the procedure when handling the drained
pulmonary secretions.
● Psychology
- Restoring a potassium deficit promotes a feeling of well-being and
stimulates appetite and activity.
● Chemistry
- Modest amounts of sodium and potassium-rich salts and sugar are
to be added to the water for therapeutic purposes.
GENERAL GUIDELINES AND NURSING
management of: fever, cough and diarrhea
INTERVENTIONS
in
the
❖ General guidelines involved in Tepid Sponge Bath
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Tepid sponging (cold sponging); application of a moist, cold liquid to the skin in
order to reduce body heat absorption and evaporation.
● Using cold sponges, a patient with hyperpyrexia can lower their
temperature.
● The body's heat can pass to the cooler solution on the surface of the body
because large regions of the body are sponged at once.
● Where blood circulation is close to the skin's surface, such as the neck,
axillae, groin, and ankles, damp towels are frequently used.
● The vital signs are monitored often to look for potential issues early on.
● Vaso-constriction, decreased blood flow, capillary permeability, lowered
metabolism, decreased blood viscosity, etc. are some physiological effects
of cold treatments.
● Because the wetness spreads the cold across a wide and deep area,
applying moist cold is more effective than applying dry cold.
● To obtain a tepid sponge or a cold sponge, a written order is required.
● When sponging, use long strokes and stay away from friction or circular
motions.
● Maintain the hot water bag at the foot of the bed ready.
❖ General guidelines involved in Chest tapping
employs one or more methods to enhance the effects of gravity and external
thoracic manipulation, such as postural drainage, percussion, vibration,
and coughing. Additionally, vibrations can be sent to the lung tissues via a
mechanical percussor.
● In postural drainage, the patient lays or sits in various positions to elevate
the area of the lung that has to be drained.
● Next, percussion, vibration, and gravity are used to drain that portion of
the lung.
● The caregiver can clap on the patient's chest wall while they are in one of
the positions for people with CF.
● This often lasts three to five minutes, and then there may be a brief
tremor over the same area for around 15 seconds (or during five
exhalations).
● The individual is then prompted to cough or puff vigorously to expel the
mucus from the lungs.
❖ General guidelines in ORESOL preparation
An oral powder known as oral rehydration solution (ORS) contains a mixture of
sodium citrate, potassium chloride, and glucose sodium chloride. They are
designed for the prevention and treatment of dehydration caused by diarrhea,
including maintenance therapy, after being dissolved in the necessary amount of
water.
● Use oral rehydration salts that are sold commercially. It is not advised to
use homemade ORS to cure dehydration. When commercial oral
rehydration salts are unavailable, these should only be taken to help avoid
or delay the onset of dehydration while traveling to get medical help.
● An oral rehydration solution is created by combining water and salts for
oral rehydration, which are commercially available. It is important to
properly follow the dosage and ORS preparation instructions. To make the
ORS, always use boiling or treated water.
● Oral rehydration salt packets are sold in most nations' pharmacies, but it
is advised to buy them before leaving Canada and pack them in your
travel health kit.
● If maintained at room temperature, ORS must be consumed or discarded
within 12 hours, or 24 hours if kept at a cooler temperature.
Nursing intervention for fever
Tepid Sponge Bath
Before
● Assess your patient's condition. This information will be used as a starting
point to assess how well the patients responded to the therapy.
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● To the patient or observer, describe the procedure. It will be much
simpler for them to cooperate if you tell them a little bit about the
procedure.
● Bring all the necessary materials and place them next to the bed. Verify
each item in your materials to make sure it is there.
- Bath basin
- Tepid water (37ºC; 98.6ºF)
4 Washcloths
Bath thermometer
Bath blanket
Patient thermometer
During
● Before beginning the treatment, carefully wash your hands.
● For privacy, close the door or the partition sheets (if at the ward).
● Set the height of the patients' beds so that it is convenient for working. As
a result, you won't have to worry about hurting your back.
● To protect the bed linens, place a bed protector or rubber sheet on the
patient's bed.
● Grab a pair of work gloves. This stops the spread of pollutants.
● To ensure privacy, carefully undress the patient, then cover him with the
bath towel.
● Pour cold water into your basin and mix it with hot water. Keep an eye on
its temperature. Ideally, the temperature should be just right. The ideal
range is between 27 and 37 degrees Celsius.
● Small towels should be submerged or dipped in the warm water. Apply it
gently to the forehead, the axilla or armpits, and the groin area while
squeezing it to prevent leakage. Repeat, if necessary, after 20 to 30
minutes of doing this. Applying compresses to areas with big superficial
blood vessels, such as the axillary and groin regions, greatly improves
heat transfer.
● For around five minutes, gently wipe the patients' extremities. then spend
the next 5 to 10 minutes working on your back and buttocks. Typically,
the chest and abdomen are excluded.
● By taking his temperature, keep track of how the patient is responding to
the treatment. If it is just a little bit higher than average, stop the
process.
After
● The patient's attire should be changed, and a light covering should be
placed over him. As far as possible, refrain from allowing your patient to
wear bulky clothing or additional bedding, as these things will only make
him feel hotter.
● Change the linens on the patient's bed and move any equipment away
from it to prevent the spread of bacteria. Next, lower the patient's bed
back to a safe height. Remove your gloves and give your hands a good,
thorough wash.
● Record the procedure that was performed, the patient's vital signs, their
reaction to the treatment, and whether any complications arose.
Nursing interventions for Cough
Chest tapping
Before
● Check for patency of the airway.
● To promote comfort, instruct the client to remove tight clothing, jewelry,
buttons, and zippers around the neck, chest and waist. Light, soft
clothing, such as a T-shirt, may be worn. Do not do CPT on bare skin.
● Keep a supply of tissues or a place to cough out the mucus nearby.
During
● The nurse clapping (percussion) on the chest wall over the area of the
emptied lung facilitates the passage of mucus into the bigger airways.
1. With postural drainage, the patient shifts their position while lying
or sitting in order to empty as much of the lung as feasible.
11
2. The caregiver can clap on the patient's chest wall while they are in
one of the positions for people with CF. This often lasts three to
five minutes, and then there may be a brief tremor over the same
area for around 15 seconds (or during five exhalations). The
individual is then prompted to cough or puff vigorously to expel the
mucus from the lungs.
3. The hand is cupped as if to hold water but with the palm facing
down (as shown in the figure below)
4. A firm beat and forceful percussion are used. Every rhythm ought
to sound hollow. Because the arm is relaxed and most of the action
is in the wrist, percussion is less demanding to perform. When the
hand is appropriately cupped, drumming shouldn't hurt or sting.
● Vibration is a technique that gently shakes the mucus so it can move into
the larger airways.
1. In order to create a delicate shaking motion, the caregiver tenses
the muscles in the arm and shoulder and places a strong touch on
the chest wall over the area of the lung being drained. The
caregiver then lightly presses the part that is vibrating.
2. The flattened hand is used for vibration, not the cupped hand (see
the figure below). Exhalation ought to be as gradual and thorough
as feasible.
After
● Perform aftercare
● Identify the patient's lung sounds
● Inquire if the person feels any relief.
Nursing interventions for Diarrhea
Making homemade ORESOL
Before
● Prepare the necessary material (below is the ratio of oresol)
○ FOR GLASS
̶
1 teaspoons of sugar
̶
Glass with 240 mL boiled water
̶
Pinch of salt
○ FOR LITER
̶
8 teaspoons of sugar
̶
A liter of water
̶
1 teaspoon of salt
● Then do medical handwashing
During
● One liter of water should contain six tablespoons of sugar.
12
● Add water to ½ teaspoon of salt.
● Combine each component. Wait until all of the components of the two
mixtures have dissolved into the water solution.
● The ORS mixture prepared is now ready for consumption.
After
● Apply aftercare
● Any salts for rehydration that have dissolved in water but haven't been
used ought to be discarded after one hour in room temp (unless stored
in a fridge, where they may be kept for 24 hours but beyond that
throw).
● Record the results and the patient's reaction.
BEGINNING SKILLS in: tepid sponge bath, chest tapping and ORESOL
preparation
Tepid sponge bath
1. Prepare the necessary materials for the procedure.
2. Perform Medical Handwashing.
3. Don the necessary Personal Protective Equipment (PPE).
4. Identify the client.
5. Explain the purpose, process, and their role in the procedure.
6. Measure the client’s body temperature and record/document the result.
7. Adjust the client’s bed, as well as the client’s position, for comfortability and
for efficient execution of the procedure.
8. Place a rubber sheet on the client's bed to protect the underlying linens.
9. Request the client to take off layers of clothing, if possible, so as to expose
the body for the sponge bathing.
10. Prepare the tepid water in a basin and make sure to keep it at an
appropriate temperature for the client.
11. Moderately soak the washcloth so as to provide comfort for the client during
the sponge bathing.
12. Once the washcloth is soaked, gently apply the wash cloth to the client’s
forehead.
13. Afterwards, soak another washcloth and gently apply to the axilla/armpits
of the client.
a. Note: Once axilla/armpit should each have a washcloth.
14. Then, soak another washcloth that is to be gently applied to the groin area
of the client.
15. The washcloths should be applied for about 20-30 minutes.
16. Afterwards, remove the washcloths and gently dry the areas with a dry
towel.
17. Replace the client’s clothing and cover the client with a light sheet/blanket.
18. Monitor the client’s temperature and document the results.
19. Perform aftercare: complete and proper collection of used materials,
medical handwashing, return the client’s bed back to its original form,
reposition client to a comfortable position, and dispose of waste materials
if any.
Armpit, inguinal and chest have a lot of blood vessels that is why it emits the most
heat
Chest tapping
1. Perform Medical Handwashing.
2. Identify the client.
3. Explain the purpose, process, and their role in the procedure.
4. Auscultate the client's lungs to determine the capability of the client to
undergo the procedure.
5. Position the client depending on the section of the lungs to undergo the
procedure.
a. Note: The procedure usually begins with the lower lobes and ends
with the upper lobes.
13
6. Then perform percussion with hands in a cupped shape, with fingers flexed
and thumbs pressed against the index fingers.
7. Afterwards, request the client to expectorate any secretions loosened by
the procedure.
8. Monitor clients for any observations that indicate immediate attention.
9. Properly and safely dispose of secretions and waste.
10. Auscultate the client’s lungs for any indications of respiratory issues.
11. Record/document the results of the procedure.
ORESOL preparation
a.)
Made at home
1. Prepare a clean container that can hold 1 liter of water.
2. Fill the container with clean water up to 1 liter.
3. Add six (6) teaspoons of sugar.
4. Add half (1/2) a teaspoon of salt.
5. Stir the mixture until the contents have dissolved.
b.)
Pre-packed formula
6. Prepare a clean container according to the serving size mentioned on the
packaging.
7. Fill the container with clean water up to the mentioned amount.
8. Pour the contents of the packaging into the container.
9. Stir the mixture until the contents have dissolved.
3. Oresol/oral rehydration solution – aqueous solution composed of glucose
and electrolytes with dehydration prevention and rehydration activities
4. Remittent – fever that remains above normal throughout the day and
fluctuates more than 1 C in 24 hours
5. Relapsing – type of fever that returns to normal for days before rising again
6. All statements are correct – In performing Chest Physiotherapy, the hand
should be cupped as if to hold water with the palm facing down. The cupped
hand curves to the chest wall and traps a cushion of air to soften the
clapping.
7. True – one importance of chest tapping is for airway clearance technique
8. Physics – Prior to performing Chest Tapping, Nurse Jeremy, makes sure to
cupped her hands and have the client position correctly.
9. Anatomy and Physiology – Nurse Anna is performing a tepid sponge bath
for a pediatric client. She knows that the procedure's goal is to lower the
body's temperature. The hypothalamus is the center of the body's
temperature regulation. This describes the principle of:
10. True
SELF ASSESSMENTS:
MODULE 1F:
1. Chest tapping/chest percussion – technique used to loosen secretions in the
lungs and respiratory tract
2. Postural drainage – type of chest physiotherapy shown in the illustration
above
14
RLE MODULE 2F: FIRST AID
(BANDAGING AND
SPLINTING)
Terms
A situation or incident that is unanticipated and
unplanned.
125.2 bandaging
It is when you cover a skin injury in order to help
stop the bleeding and prevent infection.
125.4 burns
125.5 dislocation
A condition in which the bone ends are displaced
from their natural locations.
125.6 emergency care
Refers to the initial care you should administer to
an injured or ill individual until complete medical
treatment is available.
Definition
125.1 accidents
125.3 bites
tendons, life threatening
Includes most medical services required for
immediate diagnosis and treatment of medical
condition which it not addressed immediately
may lead to death
125.7 fainting “syncope”
Wounds where the skin is only slightly damaged
or when the bite is from a human (e.g., a child)
or
a
domestic
animal
that
is
vaccinated/unvaccinated against rabies.
A temporary loss of consciousness caused by a
reduction in blood supply to the brain.
125.8 first aid
Tissue damage caused by fires, extended
exposure to sunlight or other types of radiation,
or contact with hot surfaces or chemicals.
The initial and urgent care given to anyone with
a mild or serious disease or injury, with the goal
of preserving life, preventing the condition from
worsening, or promoting recovery.
125.9 frostbite
It occurs when the skin and underlying tissues
freeze as a result of being exposed to extremely
cold temperatures.
125.10
hematoma
It is a collection of blood that has accumulated
outside the blood arteries. A blood clot that
occurs in an organ, tissue, or bodily area.
125.11
hemorrhage
A blood loss caused by damaged blood vessels. A
hemorrhage can be internal or external, and it
usually involves a large amount of bleeding in a
short period of time.
First degree burn: superficial, minor and nonthreatening
Second degree burn: affects epidermis and
parts of dermis; most painful and may cause
blisters, scarring
Third degree burn: nerves and changes color
of skin, up to subcu
Fourth degree burn: affects muscle, bone,
15
•
•
MASSIVE BLEEDING
125.12
infarction
An injury or death of tissue (as in the heart or
lungs) caused by insufficient blood flow,
particularly as a result of thrombus or embolus
obstruction of the local circulation.
TYPES
• Focal onset: aware and impaired
awareness
• Generalized onset: impaired awareness
• Unknown onset
May result to necrosis – death of body tissue
125.13
125.14
125.15
125.16
injuries
joints
poisoning
seizure
It is characterized as physical harm to your body.
It is a general term that relates to injuries caused
by accidents, falls, hits, weapons, and other
factors.
two or more bones come together to allow
movement.
125.17
shock
A serious condition brought on by an abrupt
decrease in blood flow.
125.18
splinting
Stabilizes a broken bone while injured person is
taken to hospital for advanced treatment
125.19
sprain
A ligament damage caused by tearing of the
ligament's fibers.
An injury or death caused by ingesting, inhaling,
touching, or injecting medications, chemicals,
venoms, or gases.
Changes in behavior and sudden, uncontrollable
physical movements are brought on by aberrant
electrical activity in the brain.
Wrench or twist in the ligaments violently causing
pain and swelling but not to the point of
dislocation
125.20
strain
Sudden uncontrollable electrical activity in the
brain
STAGES OF SEIZURE:
• Prodromal phase: starts a few hours
before the seizure
• Aura: last a few seconds
Ictal: body stiffens, actual seizure
Post-ictal:
tiredness,
irritability,
vomiting, and balance problems
injuries brought on by overstretching of the
muscles or tendons, which attach the muscles to
the bones.
Injury to muscle or tendon from overuse or
trauma
125.21
tourniquet
Tight bands that are used to block blood flow to
a wound in order to control bleeding.
Limits blood flow
16
125.22
trauma
A bodily injury or an event that produces longterm mental or emotional harm.
125.23
wound care
Wound care is an important process that includes
all stages of wound management in order to
avoid serious consequences. This includes
determining the type of wound, factors that
influence wound healing, and the appropriate
wound management therapy.
Ensures wound healing and prevents more
serious complications from occurring
Importance of First Aid
● It affords people with the ability to provide help during various
emergency situations.
If someone ingests hazardous substances, or suffers health-related issues like a
heart attack, or if a natural disaster occurs, a person knowledgeable in first aid
becomes more than just another bystander. Instead, they become an invaluable
support not only to victims, but also to professional emergency responders and
medical practitioners.
● First aid helps ensure that the right methods of administering
medical assistance are provided.
Knowing how to help a person is just as important in emergency situations. It only
takes six minutes for the human brain to expire due to lack of oxygen. As such,
ineptitude and misinformation will not be of much help to a person in need of
medical assistance.
● Knowledge in first aid also benefits the individuals themselves.
Whether the emergency affects themselves directly, or involves people they live
and work with, first aid stems the severity of an emergency in a given time and
place.
Aims of First Aid
● Preserve Life
As a first responder to any situation, your first priority should be to preserve life.
You may need to perform CPR, stop bleeding or take other action to preserve the
victim’s life. Start with ABC – airway, breathing and circulation Assess the quality
of the victim’s circulation, adjust if needed. Ensure that the victim has no blocks
to their airway and that they are breathing. The goal is to prevent the condition
from worsening in any way.
● Prevent Deterioration
This is all about keeping the patient’s condition stable so it does not worsen in the
time spent waiting for medical professionals to arrive. The goal is to prevent the
condition from worsening and prevent any potential further injury. This may mean
moving the victim to a safer location, applying first aid, stabilizing them, or just
staying with the victim and providing comfort.
To do this, the first responder would provide first aid treatment and reassurance.
Further injury would be guarded against and the casualty would be positioned
safely and comfortably.
● Promote Recovery
The first responder, in providing first aid treatment, would aim to relieve pain and
encourage confidence in the patient. These are important steps in helping the
recovery process.
These 3 Ps help prioritize a first responder’s actions and play an important role in
emergency treatment for victims.
Hindrances in First Aid
● Unfavorable surroundings
- Night time
- Crowded City streets
17
-
Busy Highways
Cold and rainy weather
Lack of necessary materials or helpers
● Presence of crowds
- Crowds curiously watch, sometimes heckle, sometimes offer
incorrect advice
- They may demand haste in transportation or attempt other improper
procedures
● Pressure from friends or relatives
- High expectations
- Afraid of failure
Roles, Characteristics, and Responsibilities of a First Aider
● Being a First Aider
- Provides immediate lifesaving care before the arrival of further
medical care
- Places an unconscious casualty into the recovery position
- Performs cardiopulmonary resuscitation (CPR)
- Adult: 30 compressions; 2 breaths
- Children: 15 compressions: 2 breaths
- Uses automated external defibrillators (AED)
- In cases of cardiac arrest
- Stops bleeding using pressure and elevation
- Keeps fractured part still
- Keep it as immobile as much as possible
- Performs emergency first aid at the site
- Takes universal precautions or observes Standard Operation
Procedure (SOP)
- Helps an individual who is injured or ill to keep them safe and to
cause no harm
● Characteristics
- REGORT
- Respectable
- Empathetic
- Gentle
- Observant
- Resourceful
- Tactful
● Responsibilities
- Manages the incident and ensures the continuing safety of themselves,
bystanders, and the casualty
- Assesses the casualties and find out the nature and cause of injuries
- Prioritizes casualties based upon medical need
- Prevents infection or cross-contamination by wearing Personal Protective
Equipment (PPE)
- Arranges for further medical help
- Arranges
other
emergency
services
such
as
fire/security/ambulance/evacuation
- Provides detailed information while handing over the patient to hospital
doctor
- Maintains first aid boxes
- Reports all injuries to appropriate authorities
- Shares immediate information of event with OHC/Plant in
charge/Department authorities
Principles involved in First Aid
● Anatomy and Physiology - It is important to have a basic understanding of
the structures and functions of the human body. This knowledge can help with
patient assessment, patient care, and emergency communication and reporting.
An example where this principle can be applied is when using the triangular
18
bandage. It is especially important to be familiar with basic body parts in order to
recognize different landmarks when applying the bandage.
● Body Mechanics - Proper body mechanics enables individuals to carry out
activities without expending excessive energy, and it aids in the prevention of
injuries for both patients and health care providers.
● Microbiology - Knowledge of microbiology is important in first aid because one
may be dealing with patients who may become infected due to microorganisms
and improper wound care. Rinsing the wound thoroughly, covering it properly,
changing the dressing frequently, and using antiseptics as needed all help to
prevent infection by reducing bacteria.
● Pharmacology- First responders must have sufficient knowledge of the
different medications they need to give the patient in order to provide temporary
relief while waiting for help or other healthcare team. Having knowledge about
different drugs will also contribute to helping the patient who is experiencing drug
or substance overdose.
● Sociology - In first aid, it is important to have the patient cooperate and follow
what needs to be done in order to help them effectively. There are some
procedures in first aid that require the help of the patient so establishing rapport
for their cooperation and trust is important. This is also observable as first raiders
communicate with the other healthcare members in order to provide the best
course of treatment possible.
● Chemistry - The principle of chemistry is applied when dealing with chemical
hazards. If a chemical comes into contact with the skin, immediately flush it with
water. If a chemical penetrates the clothing, remove it immediately and flush the
skin with water. This principle is also applied when using antiseptic solutions to
prevent infections.
● Physics - When creating various slings, splinting, or bandaging, ensure that
the bandage is tightly placed and that there is pressure to stop bleeding in wounds
or to avoid moving fractures or injuries. Applying too much pressure, however,
may affect the casualty's circulation. Proper positioning of materials in the right
parts is critical in ensuring no further damage will be caused.
● Time and Energy - The preserving life principle requires immediate action. A
quick response to an accident can save lives and reduce the possibility of things
worsening. If someone requires assistance due to an injury or illness, one should
not hesitate to assist.
● Safety and Security - This principle is applied when one makes sure that the
bandages are securely fastened to prevent them from becoming loose and not
supporting the injury causing other risks of injury. Making sure that the place is
safe enough to help the patient will help avoid causing more harm to the patient,
especially during natural calamities.
Bandaging
● Psychology - First responders must be able to remain calm under pressure
and contribute to lowering the overall stress levels of the injured person as well as
other people who may be concerned. In an emergency, reassurance can provide
more support than you might expect and help people make the right decisions.
Explaining the procedures to be done will also help in easing the patient’s stress
and concerns and can provide assurance to the patient of the competency of the
first aider.
19
Applying a Bandage
● Dress the wound
○ Wear gloves or other protective gear to avoid coming into touch
with the blood.
○ Use gentle soap and water to clean the wound.
○ If desired, apply a thin layer of topical antibiotic.
○ Cover the entire wound with a fresh dressing. Air can enter gauze
dressings to speed up healing. The surface of non-stick dressings is
unique and won't stick to the wound.
○ If the dressing becomes soaked with blood, cover it with another
one.
● Cover the bandage
○ Roll up some cloth or gauze strips, and wrap them around the
wound many times.
○ Extend the bandage at least an inch past the dressing on both
sides.
○ Avoid wrapping the bandage too tightly to prevent healthy tissue
from receiving blood flow.
● Secure the bandage
○ Attach the bandage with tape or a tie.
○ Avoid wrapping the bandage too firmly to prevent your fingers or
toes from turning pale or blue.
● Check circulation
○ Check circulation in the area below the bandage after several
minutes and again after several hours. If circulation is poor, the skin may
look pale or blue or feel cold. Signs of poor circulation also include
numbness and tingling.
○ If circulation is impaired, remove the bandage as soon as possible.
If symptoms persist, seek medical attention.
The Triangle of Forehead Bandage
● Place middle of base of triangle so that edge is just above the
eyebrows and bring apex backward, allowing it to drop over back
of head (occiput). Bring ends of triangle backward above ears.
● Cross ends over apex at occiput, carry ends around forehead, and
tie them in a square knot
● Turn up apex of bandage toward top of head. Pin with safety pin
or tuck in behind crossed part of bandage
Splinting
Applying Splints
● A splint should be long enough to extend beyond the injured joint
or bone. It should extend above and below the fracture point.
● Any firm or rigid material can be used for splinting, such as wood,
tongue depressor, cardboard, folded magazines or newspaper.
● Use towels, clothing, or other soft material to cushion the area to
prevent further injury.
20
● Support and fasten the splints with bandages or cloths at a
minimum of three areas:
○ Below the joint; below the break.
○ Above the joint; above the break.
○ At the level of the break; but not directly on the
injury
● Broken bones in the hands or feet can be immobilized by gently
wrapping a pillow or blanket around them to protect from further
injury.
● Apply pressure with a sterile dressing to control any serious
bleeding.
3. Until more durable splints can be used, an injured finger can be splinted
using small pieces of wood or cardboard or buddy-taped to the nearby,
unaffected fingers.
Lower Extremities
Upper Extremities
1. For immobilizing collarbone, shoulder, and upper arm injuries reaching
down to the elbow, bandages can be used to make a sling. A thick bandage
covering the person's chest is stretched around the person's body to secure
the arm sling.
2. A straight, supporting splint that secures and aligns both sides of the injury
is necessary for forearm and wrist injuries. Open hardcover books provide
an effective, quick, and portable temporary immobilizer.
1. Evaluate the foot
○ Check the temperature thoroughly
○ Check for sensation
○ Check for movement
○ Check for bruising
2. Create a cardboard splint that is broad enough along with the different
panels.
3. Pad the splint with a towel in order to bolster the foot.
4. Position the splint so that the center panel is directly under the back of the
leg and foot.
5. Secure the splint with tape after folding up the side panels.
6. Place an ice pack on the injury to help reduce the swelling and pain.
7. Reassess and go to the hospital by rechecking the circulation, sensation,
motion, and bruising after the splint has been secured
21
Slinging
Triangular Arm Sling
● Bend arm at elbow so that the little finger is about a handbreadth
above level of elbow.
● Drape upper end of triangle over uninjured shoulder.
● Slip bandage between body and arm.
● Carry lower end up over flexed forearm (ends of fingers should
extend slightly beyond base of triangle).
● Slide lower end of bandage under injured shoulder between arm
and body and secure the two ends with a square knot.
● Draw apex toward elbow until snug, and secure with safety pin
or adhesive tape.
3. Ask the casualty to let go of his injured arm. Tuck the base of the bandage
under his hand, forearm, and elbow.
4. Bring the lower end of the bandage up diagonally across his back, to meet
the other end at his shoulder.
5. Tie the ends in a reef knot at the hollow above the casualty’s collar bone.
Tuck the ends under the knot to pad it.
6. Twist the point until the bandage fits closely around the casualty’s elbow.
Tuck the point in just above his elbow to secure it. If you have a safety pin,
fold the fabric over the elbow, and fasten the point at the corner.
7. Regularly check the circulation in the thumb. If necessary, loosen and
reapply the bandage and sling.
Nursing Interventions for the following medical emergencies
Epistaxis
Interventions:
•
•
•
Elevation Sling
1. Ask the casualty to support his injured arm cross his chest, with the fingers
resting on the opposite shoulder.
2. Place the bandage over his body, with one end over the uninjured shoulder.
Hold the point just beyond his elbow.
•
Have the patient sit in an upright position and lean forward.
Keeping an upright position will reduce blood pressure in the veins of the
nose. This discourages further bleeding. Sitting forward will also prevent
the patient from swallowing blood which can irritate the stomach.
Apply continuous pressure by pinching nares together for 5-10
minutes. Direct external digital pressure to the nares with the use of index
finger and thumb must be applied. Pinching sends pressure to the bleeding
point on the nasal septum and often stops the flow of blood. Tell the patient
to breathe through the mouth.
To prevent re-bleeding, tell the patient to not pick or blow his/her nose
and don't bend down for several hours while keeping the head higher than
the level of the heart. Petroleum jelly can also be applied to the inside of
the nose using a cotton swab or finger.
If bleeding persists, cotton pledgets soaked in a vasoconstrictor and
anesthetic will be placed in the anterior nasal cavity, and direct pressure
should be applied at both sides of the nose.
22
•
Animal Bites (Snakes, dogs, or any rabid animal)
Interventions:
•
•
•
•
Stop the wound from bleeding by applying direct pressure with a clean,
dry cloth.
Wash the wound. Use mild soap and warm, running water. Thoroughly
clean the wound by washing with soap and tap water as soon as possible.
A light scrubbing should occur during the wash.
After drying, the wound should not be closed if it is a puncture wound,
but it may be covered with a dry dressing if there is a cut or laceration.
Patient should be taken to the doctor immediately. Since there is a
chance of being infected with tetanus, the doctor will administer an injection
containing tetanus vaccine. It is better to take the course of anti-rabies
treatment to provide immunity against the disease.
Wounds (Open and Closed)
Interventions:
•
•
•
•
•
•
First, wash your hands. This helps avoid infection.
Stop the bleeding. Minor cuts and scrapes usually stop bleeding on their
own. If needed, use direct pressure with a clean bandage or cloth and
elevate the wound to control bleeding and swelling.
Wash and disinfect the wound to remove all dirt and debris. Rinse the
wound with water. Keeping the wound under running tap water will reduce
the risk of infection. Wash around the wound with soap. But don't get soap
in the wound. See a doctor if you can't remove all debris.
When wrapping the wound, always use a sterile dressing or bandage.
Covering the wound keeps it clean.
o Very minor wounds may heal without a bandage.
Change the dressing. Disinfect and dry the wound thoroughly before
dressing it again. Dispose of old dressings and bandages in plastic bags.
Let the patient get a tetanus shot if he/she hasn't had one in the past
five years and the wound is deep or dirty.
Watch for signs of infection. The patient must seek a doctor if there are
signs of infection on the skin or near the wound, such as redness, increasing
pain, drainage, warmth or swelling.
Burns
Interventions:
● For minor burns:
○ Cool down the burn. After holding the burn under cool, running
water, apply cool, wet compresses until the pain subsides.
○ Remove tight items, such as rings, from the burned area. Be
gentle, but move quickly before swelling starts.
○ Avoid breaking blisters. Blisters with fluid protect the area
from infection. If a blister breaks, clean the area and gently apply
an antibiotic ointment.
○ Apply a moisturizing lotion, such as one with aloe vera. After
the burned area has been cooled, apply a lotion to provide relief
and to keep the area from drying out.
○ Loosely bandage the burn. Use sterile gauze. Avoid fluffy
cotton that could shed and get stuck to the healing area. Also
avoid putting too much pressure on the burned skin.
○ Administer over-the-counter pain reliever to the patient if
necessary. Consider acetaminophen (Tylenol), ibuprofen (Advil),
or naproxen (Aleve).
● For major burns:
○ Make sure that the patient is safe and out of harm’s way.
Move the patient away from the source of the burn. If it’s an
electrical burn, turn off the power source before touching the
patient.
○ Check to see if the patient is breathing. If needed, start rescue
breathing if you’ve been trained.
23
○ Remove restrictive items from their body, such as belts and
jewelry in or near the burned areas. Burned areas typically swell
quickly.
○ Cover the burned area. Use a clean cloth or bandage that’s
moistened with cool, clean water.
○ Avoid immersing the burned patient in water. Hypothermia
(severe loss of body heat) can occur if you immerse large, severe
burns in water.
○ Raise the burned area. If possible, elevate the burned area
above their heart.
○ Watch for shock. Signs and symptoms of shock include shallow
breathing, pale complexion, and fainting.
•
•
•
•
•
Give orals fluids to assist vomiting, if directed by a physician.
If the person vomits, turn his or her head to the side to prevent choking
and aspiration of vomitus and assist in keeping the airway open.
Poison on the skin. Remove any contaminated clothing using gloves.
Rinse the skin for 15 to 20 minutes in a shower or with a hose.
Poison in the eye. Gently flush the eye with cool or lukewarm water for
20 minutes or until the physician arrives.
Inhaled poison. Get the person into fresh air as soon as possible.
Choking (Partial or complete obstruction)
Interventions:
•
Partial Obstruction
o Ask patient to cough and expel the foreign body.
o Let the patient spit out the object if it's in his/her mouth.
•
Complete Obstruction:
o Stand behind the patient and slightly to one side. Support the
chest with 1 hand. Lean the patient forward so the object blocking
the airway will come out of the mouth, rather than moving further
down.
o Give up to 5 sharp blows between the patient’s shoulder blades
with the heel of your hand. The heel is between the palm of your
hand and your wrist.
o Check if the blockage has cleared. If not, give up to 5 abdominal
thrusts. Don't give abdominal thrusts to babies under 1 year old or
pregnant women.
o If the person's airway is still blocked after trying back blows
and abdominal thrusts, get help immediately.
o If the patient loses consciousness and is not breathing, begin
cardiopulmonary resuscitation (CPR) with chest compressions.
Frostbite
Interventions:
•
•
•
•
Rewarming of the skin. If the skin hasn't been rewarmed already,
rewarm the area using a warm-water bath for 15 to 30 minutes. The skin
may turn soft and gently move the affected area as it rewarms.
Administer oral pain medicine, if advised by the doctor as the
rewarming process can be painful and the patient will likely need a drug to
ease the pain.
Wound care. A variety of wound care techniques may be used, depending
on the extent of injury.
Whirlpool therapy or physical therapy. Soaking in a whirlpool bath
(hydrotherapy) can aid healing by keeping skin clean and naturally
removing dead tissue.
Poisoning (Irritant, narcotics, and corrosives)
Interventions:
•
Swallowed poison. Remove anything remaining in the person's mouth. If
the suspected poison is a household cleaner or other chemical, read the
container's label and follow instructions for accidental poisoning.
24
Dislocation
•
Interventions:
● Don't delay medical care. Get medical help immediately.
● Don't move the joint. Until the patient receives medical help, splint
the affected joint into its fixed position. Don't try to move a dislocated
joint or force it back into place. Attempting to move or jam a
dislocated bone back in can damage blood vessels, muscles,
ligaments, and nerves.
● Put ice on the injured joint. This can ease swelling and pain in
and around the joint by controlling internal bleeding and the buildup
of fluids in and around the injured joint.
Strain
Interventions:
•
•
•
•
•
The main treatment is RICE (rest, ice, compression, and elevation).
o Rest, to give the injured limb a break
o Put ice to affected area to dull the pain
o Apply compression to reduce the swelling
o Elevate the injury to reduce swelling and pain
Elevate or immobilize the affected joint, and apply ice packs
immediately. Assist with tape, splint or cast application, as necessary
To manage the pain, over-the-counter pain relievers may be helpful.
Physical therapy rehabilitation may be required to some strain injuries
to help the tissue heal and to retain and strengthen the muscles and
tendons.
A more severe strain may require evaluation by a doctor if the symptoms
or pain don't improve while treating the injury.
Sprain
•
•
•
After the acute inflammatory stage (24 to 48 hours after injury), heat
may be applied intermittently (for 15 to 30 minutes four times a day) to
relieve spasm and to promote vasodilation, absorption and repair.
If the sprain is severe such as torn muscle fibers and disrupted
ligaments, surgical repair or cast immobilization may be necessary so that
the joint will not lose its stability.
Instruct the client to allow the muscle or tendon to rest and repair itself
by avoiding use for approximately a week and then by progressing activity
gradually until healing is complete.
Administer prescribed medications, which may include nonopioid
analgesics.
Fractures
Interventions:
● Immediately after injury, if a fracture is suspected, it is important
to immobilize the body part before the patient is moved.
● Adequate splinting is essential to prevent the movement of
fracture fragments.
○ In an open fracture, the wound should be covered with a
sterile dressing to prevent contamination of the deeper
tissues.
● Maintain bed rest or limb rest as indicated. Provide support of
joints above and below the fracture site, especially when moving and
turning.
● Position the patient, so that appropriate pull is maintained on the
long axis of the bone. This promotes bone alignment and reduces
the risk of complications (delayed healing and nonunion).
● Elevate extremity. The affected extremity is elevated to minimize
edema.
Interventions:
•
Elevate or immobilize the affected joint, and apply ice packs immediately
o Assist with tape, splint or cast application, as necessary
25
Shock
•
Interventions:
•
•
•
•
•
•
•
•
Let the patient lie down. This is the most comfortable position. If the
patient is in pain, letting him or her rest is crucial. Pain may further intensify
stress and accelerate the progression of shock.
Call for medical help. Shock can’t be managed by first aid alone. The
patient still needs emergency medical care.
Maintain the patient’s normal body temperature. Keep him or her
warm if the body is getting cold.
If the patient is vomiting or bleeding from the mouth, turn the
patient on his or her side to prevent choking or aspiration. If you suspect a
spinal cord injury, let him lie flat on the floor.
If the patient stops breathing, open the airway and check for breathing.
Begin cardiopulmonary resuscitation (CPR). Continue until help arrives or
the patient starts breathing again.
Symptoms: sudden decrease in blood pressure
•
Promote airway clearance. Maintain a lying position, flat surface. Loosen
clothing from neck or chest and abdominal areas.
Clear away dangerous objects, if the person is moving.
Don't try to restrain someone having a seizure. Avoid putting your fingers
or other objects in the person's mouth.
Stay with the person until medical personnel arrive. Observe the person
closely so that you can provide details of the happening.
Picture
Material
Description
Cravat /
Triangular
bandage
Used as an arm sling to
support the injury.
Fainting
Interventions:
•
•
•
•
Position the person on his or her back. If there are no injuries and the
person is breathing, raise the person's legs above heart level.
Loosen constrictive clothing such as belts and collars.
Check for breathing. If the person isn't breathing, begin CPR. Continue
CPR until help arrives or the person begins to breathe.
To reduce the chance of fainting again, don't get the person up too
quickly. If the person doesn't regain consciousness within one minute, call
for help.
Seizure
Interventions:
•
Ease the patient to the floor. Turn him/her gently onto one side, this will
help the person breathe and place something soft under his or her head.
Hard splint
I.
A supportive device used to
keep in place any suspected
fracture in one’s limbs.
Bandaging - The application of a strip or roll of cloth or other material that
may be wound around a part of the body in a variety of ways to secure a
dressing, maintain pressure over a compress, or immobilize a limb or other
part of the body.
26
Materials needed for Bandaging: Cravats
Procedure Guide for Bandaging
PROCEDURE
RATIONALE
Triangular Bandages
Making a broad-fold bandage
Making a narrow-fold bandage
1. Fold a triangular bandage to make a This is a necessary step as the
semi broad-fold bandage.
narrow fold bandage requires 3
folds unlike the
semi broad-fold which requires 2.
1. Open out a triangular bandage and Opening it on a clean surface would
fold the bandage in half horizontally, prevent contamination and makes
so that the point of the triangle it easier to fold the bandage.
touches the center of the base.
2. Fold the bandage horizontally in half Folding it once more created a
again. It should form a long, narrow bandage used to apply on
narrow, thick strip of material.
smaller body parts.
2. Fold the triangular bandage in half The apex should be folded down to
again, in the same direction, so that the base twice to create a broadthe first folded edge touches the fold bandage ready for application.
base. The bandage should now form
a broad strip
Scalp Injury
1. Fold a hem along the base of the
bandage. Place the bandage on the
casualty’s head with the hem
underneath and the center of the
base just above his eyebrows.
Folding along the base creates a
cushion to support the head.
Placing the hem just above the
eyebrows ensures that the patient’s
eyes are not covered.
27
2. Wrap the ends of the bandage
securely around the casualty’s
head,tucking the hem just above his
ears. Cross the two ends at the nape
of the casualty’s neck, over the
point of the bandage.
Proper wrapping will thoroughly
secure the bandage on the
patient’s head. Ensure that the
crossed ends are not too tight and
not too loose.
of the casualty’s head. Tie ends in a
reef knot (opposite) at the centre of
the forehead, positioning it over the
hem of the bandage. Tuck the free
part of each end under the knot.
against the patient’s head. Using
this type ensures that the knot is
secure and will not slip. The tucking
is done to ensure no complications
from a stray cloth and will display
neatness.
4. Steady the casualty’s head with one
hand and draw the point down to
tighten the bandage. Then fold the
point up over the ends and pin it at
the crown of his head. If you do not
have a pin, tuck the point over the
ends.
Tightening thoroughly secures the
bandage and it also ensures
compression in order to stop the
bleeding of the injury and pinning
or tucking secures the bandage.
3. Bring the crossed-ends to the front The reef knot secures the bandage
28
2. Fold the lower end of the bandage This ensures a neat and secure
up over the forearm and bring it to sling so no complications arise.
meet the upper end at the shoulder.
Arm Sling
1. Ensure that the injured arm is
supported with the hand slightly
higher than the elbow. Fold the base
of the bandage under to form a
hem. Place the bandage with the
base parallel to the casualty’s body
and level with his little fingernail.
Slide the upper end under the
injured arm and pull it around the
neck to the opposite shoulder.
The injured arm should be given
proper support and elevation to
prevent further harm. Positioning
the injured arm on teh bandage
and sliding the upper ends around
the neck anchors the bandage in
place.
3. Tie a reef knot on the injured side,
at the hollow above the casualty's
collarbone. Tuck both free ends of
the bandage under the knot to pad
it.
A reef (square) knot is secure and
will not slip. Directing the knot in
that position prevents pressure on
the back of the neck.
29
necessary, loosen and reapply the tight, can restrict blood circulation
bandages and sling.
to teh area beyond it. If this occurs,
the bandage must be reapplied
more loosely.
Elevation Sling
4. Fold the point forward at the To hold the arm securely and to
casualty's elbow. Tuck any loose display neatness.
fabric around the elbow, and secure
the point to the front with a safety
pin. If you do not have a pin, twist
the point until the fabric fits the
elbow snugly; tuck it into the sling
at the back of the arm.
1. Ask the casualty to support his To support the injured area before
injured arm cross his chest, with the bandages are applied and to
fingers resting on the opposite prevent further injury.
shoulder.
2. Place the bandage over his body, To restrict and immoblize the
with one end over the uninjured injured shoulder.
shoulder. Hold the point just beyond
his elbow.
5. As soon as you have finished, check Checking circulation is important
the circulation in the fingers. because limbs can swell after an
Recheck every 10 minutes. If injury, and a bandage, if done too
30
to pad it.
3. Ask the casualty to let go of his To allow the nurse to start the
injured arm. Tuck the base of the process
of
supporting
and
bandage under his hand, forearm, stabilizing the injury.
and elbow.
6. Twist the point until the bandage
fits closely around the casualty’s
elbow. Tuck the point in just above
his elbow to secure it. If you have
safety pin, fold the fabric over the
elbow, and fasten the point at the
corner.
prevents any complication that a
stray cloth may bring.
Twisting the point is to hold the
elbow securely, avoid any injury,
and display neatness. Circulation
must be checked to know whether
nerves are damaged, and if so, the
bandage must be redone to be not
too tight.
4. Bring the lower end of the bandage To allow the sling to raise the
up diagonally across his back, to injured arm and bring it closer to
meet the other end at his shoulder. the body.
5. Tie the ends in a reef knot at the A reef (square) knot is secure and
hollow above the casualty’s collar will not slip. Tucking the excess
bone. Tuck the ends under the knot fabric ensures neatness and it also
7. Regularly check the circulation in To check circulation is important
the thumb. If necessary, loosen and because limbs can swell after an
reapply the bandage and sling.
injury, and a bandage, if done too
tight, can restrict blood circulation
to teh area beyond it. If this occurs,
the bandage must be reapplied
more loosely.
31
II. Splinting - The process of immobilizing, restraining or supporting a body part;
stabilization, immobilization and/ or protection of an injured body part with a
supportive appliance.
Materials needed for Splinting: Hard Splints
2. Position the arm on a rigid splint
The rigid splint will immobilise the
arm.
3. Secure the splint
A bandage is used to secure the splint
in place.
Procedure Guide for Splinting
PROCEDURE
RATIONALE
Triangular Bandages
Arm Sling and Binder
1. Support the arm
To ensure that no further harm will
happen.
32
4. Check circulation
Circulation must be checked to
prevent injury to the nerves and other
tissues. This can be checked through
the patient’s fingernails. If circulation
is poor, the bandage must be
adjusted, making sure it is not too
tight.
5. Position the triangular bandage.
To use for the arm sling the patient
will use.
6. Bring the lower end of the To have both ends ready to be tied
bandage to the opposite side of around the patient’s neck.
the neck.
7. Tie the ends using a square knot
A square knot is secure and will not
slip.
33
8. Secure the point of the bandage To ensure that it fits the elbow snugly
at the elbow.
and secure the bandage.
Splinting the Leg
9. Tie a binder bandage over the To secure the arm of the patient.
sling around the chest.
1. Gently slide 4 or 5 bandages or To secure the splint in place.
strips of cloth under both legs.
34
2. Put padding between the legs.
To use as a cushion for both legs so
that they will not come in contact.
4. Tie the bandages
To securely fasten the splint and
bandages in place.
3. Gently slide the uninjured leg next This must be gently done to not cause
to the injured leg.
further injury to the injured leg.
35
RLE MODULE 3F: TRANSFER
AND AMBULATION
DEFINITION OF TERMS
1.1 Transfer
- The act of moving a person with limited function from one location
to another.
1.4 Non-ambulatory
- An individual physically or mentally unable to walk or traverse a
normal path to safety without the physical assistance of another.
1.2 Ambulation
- The capacity to move independently from one location to another
while using or without a mobility aid.
1.5 Alignment
- Refers to how the head, shoulders, spine, hips, knees and ankles
relate and line up with each other.
1.3 Ambulatory
- Promotion and assistance with walking to maintain or restore
autonomic and voluntary body functions during treatment and
recovery from illness or injury
36
1.6 Braces
- A medical device used in orthopedics to retain, align, or support a
body part in the proper position
1.7 Canes
- Canes or walking canes are one of several devices available to assist
in ambulation, or walking.
1.8 Carry
- To hold or support while moving
1.9 Crutches
- Is a wooden or metal staff used to aid a patient’s mobility impairment
or an injury that limits walking ability.
1.10 Gait
- The way or manner in which you walk. Depends on how well a person
can balance and support their weight.
1.11 Hydraulic lift
- A tool that can help transfer an immobile or obese patient safely from
the bed to a chair.
37
1.14 Movement
- The act or process of moving.
1.12 Lift sheet
- The medical field uses this sheet to get immobile patients out of bed.
It is around the size of a typical sheet and is available in cotton,
plastic, or rubber. When lifting, it provides support for the body from
the upper back to the mid-thigh.
1.13 Mobility
- The quality or state of being mobile.
1.15 Orthostatic hypotension
- A client's blood pressure that drops when they stand or sit suddenly.
It typically results from peripheral vasodilatation, in which blood
departs from central body organs, particularly the brain, and flows
to the periphery, frequently making the person feel dizzy.
38
1.16 Stretcher
- A device used for carrying a sick, injured, or dead person.
1.19 Weight
- A measure of the heaviness of an object.
1.20 Wheelchair
- Is a device used for mobility by people for whom walking is difficult
or impossible, due to illness or disability.
1.17 Transfer belt
- A device used primarily to help a patient to transfer between bed
and wheelchair or wheelchair and toilet or car.
1.18 Walker
- An enclosing framework of lightweight metal tubing, sometimes with
wheels, for patients who need more support in walking.
CLO#2: discuss the importance, indications and contraindications, and factors
affecting transfer and ambulation
Importance of Transfer and Ambulation
Transfer
● Permits a patient to function in different environments
● Increases the level of independence of the patient
39
● Maximizes the ability to encompass a task with minimal effort and
maximum safety
● Mobilizes client without causing injury and falls
● Prevents systematic hazards of immobilization
Ambulation
● Stimulates blood circulation throughout the body, preventing inflammation
in the veins and the development of stroke-causing clots
● Improves joint flexibility, especially that of the hips, knees, and ankles
● Assures fast healing; helps the patients in building strength and muscle
tone, which eventually leads to improvement of oxygen delivery into the
blood tissues
● Enhances the movement of their abdominal muscles; gradually helps in
stimulating the intestinal tract and therefore prevents constipation
● Prevents urinary tract incontinence and infection; clients are able to go to
the bathroom on their own
● Relieves pressure on the body and skin, which helps prevent ulcers
● Feelings of independence helps improve client’s self-esteem
Indications of Transfer and Ambulation
Transfer
● Client needs to be transported to another room or unit
● Client has a treatment or diagnostic test
● Client who is permitted out of the bed
Ambulation
● Client's need for mobility
● Elderly person
● Pregnant women
● Post-surgery clients
● Continued bed exercise for muscle strengthening
Contraindications for Transfer and Mobility
Transfer
● Clients who have spinal injury
● Clients who have undergone spinal surgery
● Clients that have severe wounds or burns
Ambulation
● Spinal injury
● Paralyzed legs
● Contraindicated by the doctors
Factors Affecting Transfer and Ambulation
Transfer
● Postoperative clients
● Existing injuries or wounds
● Unfamiliarity with equipment
● Inexperienced provider
● Poor communication with the receiving facility
Ambulation
● Postoperative clients
● Severe trauma clients
● Patients on complex medications and/or infusion regimes
● Insufficient preparation of the client
● Poor communication with the receiving facility
CLO#3: explain the principle involved in transfer and ambulation
3.1 Body Mechanics
- Body mechanics involves standing and moving one's body so as to
prevent injury, avoid fatigue, and make the best use of strength.
You can safely control and move another person if you learn to
control and balance your own body.
3.2 Safety and Security
- This procedure involves safety and security to prevent and reduce
risks, errors, and harm to patients and health providers while
providing health care.
3.3 Microbiology
- Maintaining a clean surrounding and of course doing hand washing
before getting contact with the client is a must to avoid possible
infections.
3.4 Psychology
- Proper approach to the patient and administration in transferring
the patient will let the patient feel safe and away from worrying
40
that anything bad will happen.
3.5 Physics
- Physics is involved in the procedure in terms of the energy and
force in transferring the patient and the friction between the
patient and the board. Also when the health providers keep the
heaviest part of the patient near the health providers center of
gravity for stability.
3.6 Anatomy and Physiology
- Having enough knowledge about the Anatomy and Physiology will
allow the care provider to easily determine which part of the body
would be the heaviest or the lightest or which part of the patient
should be taking care of.
3.7 Time and Energy
- Preparing the materials needed in transferring the patient and
ambulation requires enough time and energy. Also when they are
transferring the patient they need sufficient energy to position and
transfer the client to the stretcher.
-
Patient-handling tools mostly utilized in pre-hospital trauma care.
Purpose: to give a person with suspected spinal or limb damage
stiff support while they are moving.
4.1.3 Wheel chair
- a wheeled chair that is used when walking is difficult or impossible
because of an illness, injury, age- or disability-related issues.
Purpose: specifically made to be used for indoor or both indoor and
outdoor locomotion by a person with a mobility impairment.
CLO#4: describe the mechanical devices used in transferring and ambulating
patients as to its description and purpose.
4.1 Mechanical devices used in transferring patients:
4.1.1 Stretcher
- a tool or equipment that stretches or expands material.
Purpose: to lift a person who must lie flat and is unable to move
independently.
4.1.4 Transfer belt
- equipment that a caregiver places on a patient with mobility
problems before transporting the patient.
Purpose: to help a patient safely transition from a standing position
to a wheelchair
4.1.2 Spine board
41
4.1.5 Hydraulic lift
- Devices for transferring patients from beds to wheelchairs,
commodes by the bed, and bathtubs
Purpose: utilized with patients who are too heavy to be properly
moved by members of the healthcare team, have physical
restrictions such amputations or quadriplegia, or who are unable to
bear weight at all.
4.2.2 Walkers
- a four-point walking assistance that makes contact with the
ground.
Purpose: help stabilize patients who have lower extremity disability
or poor balance and mobility.
4.2.3 Crutches
- Medical devices that shift bodily weight from the legs to the torso
and arms to help with ambulation.
Purpose: utilized to help people who have neurological disability or
lower extremity injuries.
4.2 Mechanical devices used in ambulating patients:
4.2.1 Canes
- a device that offers a little balance and support for walking and
standing.
Purpose: to help people who are weak, unsteady, in pain, or have
lost their balance during ambulation and transfers.
CLO#5: explain the guidelines in the measurement of crutches and proper use of
crutches
42
5.1 Measurement of Crutches
The handgrips of the crutches should be at a height which
allow elbows to be bent at about 30°. Adult and children – measure
from position of hand by side when elbow is 30° bent, with patient
standing upright, to ground 4 inches away from side of foot.
5.2 Measurement of Axillary Crutch
MEASUREMENT OF AUXILIARY CRUTCHES
With patients’ shoes on, stand tall. Put their arms below the
crutches. Let their arms swing down over the crutches with ease.
With their hands hanging loosely, there should be two inches
between their armpit and the top of the crutch. When holding the
hand grips, they should be level with patients’ wrist. Their elbows
should be slightly bent at a 30-degree angle.
5.3 Measurement of Elbow Crutch
MEASUREMENT OF ELBOW CRUTCHES
If the patient is standing up straight, measure from the side
of the hand where the elbow is bent by 30 degrees to the
distance of the ground, which should be 4 inches. Height
should be adjusted to allow for 20–30 degrees of elbow
flexion while keeping shoulders relaxed.
5.4 Guidelines in proper use of crutches
Proper Use of Crutches
Stand upright. Put the crutches' tops under their arms. Place
the ends 5 to 8 inches (or 12 to 20 cm) to the side of your
feet. If there is 2 to 3 fingers between the top of the crutch
pad and the patient's armpit, the crutches are the right
length. When their arm is hanging by their side, the hand
grasp should be at wrist level. As the patient presses down
on the hand grips, their elbows are slightly bent.
Remember: The weight should be supported with the hand grips,
not the crutch pads under your armpits.
5.4.1 Proper positioning
● When standing up straight, the top of your crutches
should be about 1-2 inches below your armpits.
● The handgrips of the crutches should be even with
the top of patients’ hip line.
● Patients’ elbows should be slightly bent when holding
the handgrips.
● To avoid damage to the nerves and blood vessels in
patients’ armpits, their weight should rest on your
hands, not on the underarm supports.
5.4.2 Proper walking
● Lean forward slightly and put your crutches about
one foot in front of you.
● Begin your step as if you were going to use the
injured foot or leg but, instead, shift your weight to
the crutches.
● Bring your body forward slowly between the crutches.
Finish the step normally with your good leg. When
your good leg is on the ground, move your crutches
ahead in preparation for your next step. Always look
forward, not down at your feet.
5.4.3 Proper sitting
● The patient positions himself or herself at the center
front of the chair with the posterior aspect of the legs
touching the chair.
● Then the patient holds both crutches in the hand
opposite the affected weight-supporting braces.
● The patient holds the crutches in the hand on his or
her stronger side.
43
5.4.4 Proper standing up
● Patient should inch themselves to the front of the
chair.
● Hold both crutches in the hand of the injured side.
● Patient should push up and stand on their good leg.
5.5.5 Using the stairs with crutches
● (Ascending stairs)
○ The patient usually uses a modified three-point gait.
○ He/she stands at the bottom of the stairs and
transfers body weight to the crutches .
○ He/she advances the unaffected leg between the
crutches to the stairs.
○ The patient then shifts weight from the crutches to
the unaffected leg.
○ Finally he/she aligns both crutches on the stairs.
○ The patient repeats this sequence until he or she
reaches the top of the stairs.
● (Descending stairs)
○ A three-phase sequence is also used to descend the
stairs
○ The patient transfers body weight to the unaffected
leg.
○ He/she places the crutches on the stairs and begins
to transfer body weight to them, moving the affected
leg forward.
○ Finally the patient moves the unaffected leg to the
stairs with the crutches.
○ The patient repeats the sequence until reaching the
bottom of the stairs.
CLO#6: explore safety points or issues when a patient is on a stretcher and
wheelchair and the basic guidelines in transferring and ambulating patients
6.1 Safety points to consider when using a Stretcher
Properly Place the Stretcher - Properly placing a stretcher into an ambulance is a
part of proper stretcher handling. If a stretcher is in the ambulance, make sure
that it is firmly fastened to prevent movement while the patient is being
transported to the hospital.
Look at the Stretcher’s Legs - Inspection of the Stretcher’s leg is very advisable
since some screws or nuts may be loosened and it must be tightened due to
usage. To avoid any accidents, the stretcher must be examined and made sure
it is fastened in place.
Check the Wheels on the Stretcher - Checking the wheels of a stretcher ensures
the safety of the patients. Some stretcher brakes are not functioning well due to
usage of which.
Assess the Weight of the Patient - Stretchers are designed to be durable.
Stretchers must be able to support the patient's weight even though they are
made to be sturdy. Stretchers must be able to support the patient's weight even
though they are made to be sturdy.
Opt for Level Ground When Possible - A stretcher should be placed on flat
ground for the safety of both the transporter and the patients. This is advised to
avoid an accident where one of the EMS personnel loses their balance or footing.
Hold the Handles During Transfers - The handles must be grasped as the
stretcher is pushed into the location where it will be put when patients are
transferred into or out of an ambulance. Medical workers should release their
grip on the handles only after the stretcher is in position. During transfers from
stretcher to bed or the other way around, the stretcher's handles should be
tightly grasped.
44
6.2 Safety points to consider when using a wheelchair
in both LE.
● Provides
best
balance &
stability for
person but
must be
able to
weight
bear on
both legs
with your right
foot. The pattern is
right crutchleft foot
and left crutchright foot.
This gait pattern
is used when one
of the lower
extremities (LE) is
unable to fully
bear weight (due
to fracture,
amputation, joint
replacement,
etc).
● Allows the
individual
to
eliminate
all the
weightbearing on
the
affected
leg
There are three
points of contact
with the floor. The
crutches serve as
one point, the
involved leg as the
second point, and
the uninvolved leg
as the third point.
Both crutches
move forward, the
affected limb then
steps up to the
crutches. This is
followed by the
weight-bearing
limb which steps
through, beyond
the crutches. There
are always three
points of contact
with the floor at
any given time.
Make sure the patient's seat belts are securely fastened - Being buckled in any
type of device or vehicle helps you keep safe and secure. If you don't buckled up
with seat belt this might throw you rapidly and can cause accident.
Patients feet are on the footplate - The stability of a patient's fully loaded feet on
the proper footplate can lower the chance of slipping and falling out of the chair
and helps maintain excellent posture while seated.
Always lock the brakes before getting in and out of the wheelchair - Before a
patient will sit in a wheelchair we must first check and lock the brakes for a
sudden stop or if not, it will lead you to an accident.
Regular Maintenance is very important - Providing regular check up for the
wheelchair is a must, thus this will help prolong the life of the device. Also this
will help you know what to repair when it is broken.
Avoid putting heavy loads on the back of a wheelchair - Avoid placing any kind of
things which are heavy thus this will cause the wheelchair to tip backwards in
transferring the patients. Only attach useful and light items for your safety.
CLO#7: Discuss the different type of gaits and carry including its indications,
advantages and guidelines
7.1 Types of gait
Type of gait
Indications
1. Four-point gait
This gait pattern
is most commonly
used when there
is a lack of
coordination,
poor balance and
muscle weakness
Advantages
● It provides
a slow and
stable gait
pattern
with four
points of
support.
Guidelines
To use this gait,
put
the right crutch out
and step with the
left foot. Then put
the left
crutch out and step
2. Three-point
gait
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3. Two-point gait
4. Swing-To gait
This gait pattern
is used when the
patient can bear
some weight on
both lower
extremities.
● Faster
than a
Four point
gait.
Place the patient in
the tripod position
and instruct him to
do the following:
1. Move the
right leg and
left crutch
forward
together.
2. Move the
left leg and
the right
crutch
forward
together.
3. Repeat this
sequence
for the
desired
ambulation.
Also known as
"step-to", this
gait type is
common with
individuals with
limited use of
both lower
extremities
and/or trunk
instability (one or
both feet make
contact with the
floor).
● Provides
stability
● Can use
this gait
with a
walker.
Place the patient in
the tripod position
and instruct him to
do the following:
1. Advance
both
crutches
2. Lift both
feet/Swing
forward/land
feet next to
crutches
3. Repeat the
sequence in
rhythm for
desired
ambulation.
5. Swing-Through This gait pattern
is used for
patients with
lower extremities
that are
paralyzed and/or
in braces.
● Faster, but
requires
more
energy
Place the patient in
the tripod position
and instruct him to
do the following:
1. Move both
crutches
forward
together
about 6
inches.
2. Move both
legs forward
together
about 6
inches.
3. Repeat the
sequence in
rhythm for
desired
ambulation.
7.2 Types of Carry
Type of carry
Indications
Advantages
Guidelines
One-Person help
1. One-Person
Walk Assist
This type of carry
is used when the
victim can selfextricate with
● The oneperson walk
assist offers
the least
1. Place victim's
arm around your
neck and hold
their wrist
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2. Firefighter
Carry
3. Pack Strap
Carry
little or no
assistance as
walking wounded.
chance for
injury to
both
rescuer and
victim.
2. Place your arm
nearest to them
around their waist
and walk with
them to safety
This type of carry
should only be
conducted by a
very strong
rescuer and a
smaller victim.
● It allows
the rescuer
to move the
victim
across
significant
distances,
quickly, the
technique is
used to
carry
injured
people
away from
danger.
1. With victim
lying down, hook
your elbows
under their
armpits
2. Raise them to
a standing
position
3. Place your right
leg between the
victim's legs
4. Grab the
victim's right
hand with your
left
5. Squat and
wrap your right
arm around the
victim's right knee
6. Stand and raise
the victim's right
thigh over your
right shoulder
● It is a
quick,
down-and-
1. Facing away
from the victim,
place their arms
The pack-strap
carry is generally
used to carry a
conscious or
unconscious
casualty for a
moderate
distance. This
carry is not used
if the casualty has
a broken arm or
wrist.
dirty way to over your
move a
shoulders.
victim
2. Cross the
quickly.
victim's arms
grasping the
opposite wrist
and pull close to
your chest.
3. Squat, lean
slightly forward,
and drive your
hips into the
victim as you
stand.
Two-Person help
1. Two-Person
Extremity Carry
This type of carry
is best suited for
moving a victim
over even terrain,
such as along a
paved path or
within a building.
● It is easily
performed
● Both
conscious
and
unconscious
victims can
be carried
in this
manner.
1. Help the victim
to a seated
position.
2. First rescuer
kneels behind the
victim, reaches
under their arms,
and grabs their
wrists.
3. Second rescuer
backs between
the victim's legs,
squats down, and
grabs behind the
knees.
4. Stand at the
command of the
rescuer at the
head, focusing on
47
using your legs
rather than your
back.
2. Chair Carry
3. Two-Handed
Seat Carry
This is a
particularly good
method to use
when you must
carry a person up
or down stairs or
through narrow,
winding
passageways.
● This makes
the
transport of
a victim
significantly
easier on
the
rescuers.
1. Place victim in
a sturdy chair
2. First rescuer
stands behind,
grabs the back of
the chair, and
leans it back on
its hind legs
3. Second rescuer
backs to the
chair, squats
down, and grabs
the front legs of
the chair
4. Stand at the
command of the
rescuer at the
head
The two-handed
seat carry should
only be
conducted on
conscious victims.
● This
technique is
for carrying
a victim
longer
distances.
1. Each rescuer
should kneel on
either side of the
seated victim.
2. Link arms
behind the
victim's back.
3. Place your free
arms under the
victim's knees and
link arms.
4. Place victim's
arms around the
shoulders of
rescuers and
stand together.
Three-Person help
1. Hammock carry This type of carry
is helpful when
the patient is
unconscious or
cannot move and
needs to be
moved.
● Efficient for
patients
that are
heavier
than the
average
person.
1. Reach under
the victim and
grasp one wrist
on
the opposite
rescuer.
2. The rescuers
on the ends will
only be able to
grasp one wrist
on the opposite
rescuer.
3. The rescuers
with only one
wrist grasped will
use
their free hands
to support the
victim's head and
feet/legs.
4. The rescuers
will then squat
and lift the victim
on the command
of the person
nearest the head,
remembering to
use proper lifting
techniques.
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2. Three-person
carry or Stretcher
lift
This technique is
for lifting patients
onto a bed or
stretcher, or for
transporting them
short distances.
● Help
protect
victims
from
further
injuries and
provide
greater
stability for
patients.
1. Each person
kneels on the
knee nearest the
victim's feet.
2. On the
command of the
person at the
head, the
rescuers lift the
victim up and rest
the victim on their
knees.
If the patient is
being placed on a
low
stretcher or litter
basket:
3. On the
command of the
person at the
head, the
patient is placed
down on the
litter/stretcher.
If the victim is to
be placed on a
high
gurney/bed or to
be carried: At this
point, the
rescuers will
rotate the victim
so that the victim
is facing the
rescuers, resting
against the
rescuers' chests.
3. On the
command of the
person at the
head, all
the rescuers will
stand.
4. To walk, all
rescuers will start
out on the same
foot, walking in a
line abreast.
CLO#8: discuss nursing responsibilities before, during and after ambulating and
transferring patients.
CLO#9: demonstrate the beginning skills.
9.1 Transferring patients from bed to chair to wheelchair
Safety considerations:
● Check rooms for additional precautions
● Introduce yourself to patient
● Confirm patient ID using two patient identifiers (e.g., name and date of
birth)
● Listen and attend to patient cues
● Ensure patient’s privacy and dignity
● Assess ABCCS(airway, breathing, circulation, consciousness,
safety)/suctions/oxygen/safety
● Ensure tubes and attachments are properly placed prior to the
procedure to prevent accidental removal
49
● A gait belt and wheelchair are required
PROCEDURE
RATIONALE
a patient has weakness on one side,
place the wheelchair on the strong
side.
1. One health care provider is required. The patient should be assessed as a 1person assist.
2. Perform hand hygiene. Explain what This step provides the patient with an
will happen during the transfer and opportunity to ask questions and help
how the patient can help.
with the positioning.
Apply proper
ambulation
footwear
prior
to
Wheelchair with one leg rest removed
4. Sit patient on the side of the bed The patient’s feet should be in between
with his or her feet on the floor. Apply the health care provider’s feet.
the gait belt snugly around the waist (if
required).
Explain procedure to patient
Proper footwear
Place hands on waist to assist into a
standing position
Patient position prior to standing
3. Lower the bed and ensure that Ensure brakes are applied on the
brakes are applied.
wheelchair.
Place the wheelchair next to the bed at
a 45-degree angle and apply brakes. If
50
5. As the patient leans forward, grasp
the gait belt (if required) on the side
the patient, with your arms outside the
patient’s arms. Position your legs on
the outside of the patient’s legs. The
patient’s feet should be flat on the
floor.
Assist to a standing position using a
gait belt
6. Count to three and, using a rocking
motion, help the patient stand by
shifting weight from the front foot to
the back foot, keeping elbows in and
back straight.
Assist into the wheelchair
8. As the patient sits down, shift your This allows the patient to be properly
weight from back to front with bent positioned in the chair and prevents
knees, with trunk straight and elbows back injury to health care providers.
slightly bent. Allow patient to sit in
wheelchair slowly, using armrests for
support.
Weight shift to back leg by health care
provider
7. Once standing, have the patient take Ensure the patient can feel the
a few steps back until they can feel the wheelchair on the back of the legs prior
wheelchair on the back of their legs. to sitting down.
Have the patient grasp the arm of the
wheelchair and lean forward slightly.
Transfer to wheelchair
9.2 Transferring from bed to stretcher and vice versa
51
●
●
●
●
●
●
●
●
●
Safety considerations:
Perform hand hygiene
Check room for additional precautions
Introduce yourself to patient
Confirm patient ID using two patient identifiers (e.g., name and date of
birth)
Listen and attend to patient cues
Ensure patient’s privacy and dignity
Assess ABCCS (airway, breathing, circulation, consciousness,
safety)/suctions/oxygen/safety
Ensure tubes and attachments are properly placed prior to the
procedure to prevent accidental removal
A slider board and full-size sheet or friction-reducing sheet is required
for the transfer
PROCEDURE
Chin tucked in and arms across chest
3. Raise bed to safe working height. Safe working height is at waist level for
Lower head of the bed and side rails.
the shortest health care provider.
Position the patient closest to the side The patient must be positioned
of the bed where the stretcher will be correctly prior to the transfer to avoid
placed.
straining and reaching.
RATIONALE
1. Always predetermine the number of Three to four health care providers are
staff required to safely transfer a required for the transfer.
patient horizontally.
2. Explain what will happen and how This step provides the patient with an
the patient can help (tuck the chin in, opportunity to ask questions and help
keep hands on chest).
with the transfer.
Collect supplies.
May need additional health care
providers to move the patient to the
side of the bed.
4. Roll patient over and place slider The slider board must be positioned as
board halfway under the patient, a bridge between both surfaces.
forming a bridge between the bed and
the stretcher.
The sheet must be between the patient
and the slider board to decrease
Place sheet on top of the slider board. friction between patient and board.
The sheet is used to slide patient over
to the stretcher.
The patient is returned to the supine
position.
Patient’s feet are positioned on the
slider board.
Stretcher and slider board
Place slider board
52
Ensure all tubes and attachments are
out of the way.
5. Position stretcher beside the bed on The position of the health care
the side closest to the patient, with providers keeps the heaviest part of
stretcher slightly lower. Apply brakes. the patient near the health care
providers’ centre of gravity for stability.
Two health care providers climb onto
the stretcher and grasp the sheet. The
lead person is at the head of the bed
and will grasp the pillow and sheet. The
other health care provider is positioned
on the far side of the bed, between the
chest and hips of the patient, and will
grasp the sheet with palms facing up.
Caregiver at the head of the bed
The two caregivers on the stretcher
grasp the draw sheet using a palms up
technique, sitting up tall, and keeping
their elbows close to their body and
backs straight.
The caregiver on the other side of the
bed places his or her hands under the
patient’s hip and shoulder area with
forearms resting on bed.
7. The designated leader will count 1, Coordinating the move between health
2, 3, and start the move.
care providers prevents injury while
transferring patients.
The person on the far side of the bed
will push patient just to arm’s length Using a weight shift from front to back
using a back-to-front weight shift.
uses the legs to minimize effort when
moving a patient.
At the same time, the two caregivers
on the stretcher will move from a
sitting-up-tall position to sitting on their
heels, shifting their weight from the
front leg to the back, bringing the
patient with them using the sheet.
8. The two caregivers will climb off the
stretcher and stand at the side and
grasp the sheet, keeping elbows
tucked in.
The step allows the patient to be
properly positioned in the bed and
prevents back injury to health care
providers.
One of the two caregivers should be in
line with the patient’s shoulders and
the other should be at the hip area.
On the count of three, with back
straight and knees bent, the two
caregivers use a front-to-back weight
shift and slide the patient into the
middle of the bed.
Caregiver at the head of the bed
Weight on front leg
Shift weight to back foot
53
9. At the same time, the caregiver on This step allows the patient to lie flat
the other side slides the slider board on the bed.
out from under the patient.
10. Replace pillow under head, ensure This promotes comfort and prevents
patient is comfortable, and cover the harm to patient.
patient with sheets.
11. Lower bed and lock brakes, raise Placing bed and side rails in a safe
side rails as required, and ensure call position reduces the likelihood of injury
bell is within reach.
to patient. Proper placement of call bell
facilitates patient’s ability to ask for
Perform hand hygiene.
assistance.
Bed in lowest position, side rail up,
call bell within reach
Hand hygiene reduces the spread of
microorganisms.
Hand hygiene with ABHR (AlcoholBased Hand Rub)
9.3 Proper transport of patient using: stretcher and wheelchair (flat
or level surface, ramps or inclined surfaces, through doors and
elevators), canes, crutches, and walkersa
9.3.1 Stretcher
● Use hall ceiling mirrors at intersections before turning corners.
● Lock stretcher brakes when standing still.
● Always push a stretcher from the end where the client’s head is
positioned as this position protects the client’s head in the event of a
collision.
● Fasten safety straps across the client on a stretcher and raise the side
rails.
● Ramps or inclined surfaces:
- Stand at the head of the stretcher to push the stretcher up a
ramp.
- Back down a steep ramp while positioned at the head of the
stretcher
● Doors and elevators:
- Lock elevator door open when entering or exiting.
- Maneuver the stretcher when entering the elevator so that the
client’s head goes in first
9.3.2 Wheelchair
● Flat or level surfaces:
- Lock brakes when the wheelchair is standing still.
- Intravenous infusion bags can be placed on portable IV poles
attached to the wheelchair during transport.
- Ensure the client is positioned well back in the seat of a
wheelchair.
- Use seat belts that fasten behind the wheelchair to protect
confused patients from falls.
54
● Ramps or inclined surfaces
- Back slowly down wheelchair ramps.
- Push the wheelchair ahead of you when going up ramps or
inclined surfaces.
- Place your body between the wheelchair and the bottom of an
incline.
● Doors and elevators:
- If going through a self-closing door, back the wheelchair out of
the room. You can keep the door open by backing against the
door. The wheelchair can then be guided out of the room.
- When pushing a wheelchair, back into and out of elevators. Rear
large wheels first.
9.3.3 Canes
Proper positioning
● When standing up straight, the top of the cane should reach to the
crease in the patient’s wrist.
● The elbow should be slightly bent when holding the cane.
● The cane should be held in the hand opposite the side that needs
support. For example, if the patient’s right leg is injured, the cane
should be held in the left hand.
Walking
● To start, assist the client to set the cane about one small stride ahead of
the patient and step off on the injured leg.
● Inform the client to finish the step with the patient’s functional leg.
Stairs
● To climb stairs:
- Place the cane in the hand opposite the patient’s injured leg.
- With their free hand, assist the patient to grasp the handrail.
- Instruct the client to step up on their good leg first, then step up
on the injured leg.
● To come down stairs:
- Put the cane on the step first
- Then, inform the patient to put their injured leg on the step.
- Finally, put the good leg, which carries their body weight, on the
step.
9.3.4 Crutches
Proper positioning
● In assisting the patient with the use of crutches, make sure that the top
of the crutches are about 1-2 inches below the patient’s armpits.
● Handgrips of the crutches should be even with the top of the patient’s
hip line.
● When holding the handgrips, elbows must be slightly bent
● The patient’s weight should rest on their hands and not on the
underarm supports to avoid damage to the nerve and blood vessels in
the armpit area.
Walking
● Assist the patient in slightly leaning forward and place the crutches
about one foot in front of them.
● Instruct the patient to begin taking a step as if they were to use the
injured foot/leg by shifting their weight onto the crutches.
● Allow them to bring their body forward in a slow manner between the
crutches making sure not to stay too far from the client. Help the client
in finishing the step normally with their functional leg.
● When the functional leg is on the ground, instruct the client to move the
crutches in preparation for their next step.
● Advice the client to always look forward when walking and not down at
their feet.
Sitting
● To sit:
- Make sure the client is situated in front of a sturdy chair.
- Instruct the client to place their injured foot in front of them and
hold both crutches in one hand.
- Assist the client’s positioning making sure they are in line with
the seat of the chair then slowly lower them into the chair.
- Once seated, inform the patient to lean their crutches in a nearby
spot making sure to lean them upside down as crutches tend to
fall over when leaned on the tips.
● To stand up:
- Assist the client in moving forward to the front of their chair.
- Both crutches must be held by the hand on their injured side.
- Assist the client in pushing them up to let them stand on their
55
functional leg.
9.3.5 Walkers
Positioning
● When standing up straight, the top of the walker should reach to the
crease of the patient’s wrist.
● The elbows should be slightly bent when holding the handgrips of the
walker.
● Observe client making sure their is back straight not hunching over the
walker.
● Check to be sure the rubber tips on the walker's legs are in good shape.
If they become uneven or worn, new tips may be purchased at a drug
store or medical supply store.
Walking
● First, assist the client in positioning the walker about one step ahead of
them, making sure that all four legs of the walker are on even ground.
● With both hands, the patient should grip the top of the walker for
support and move their injured leg into the middle area of the walker.
Not letting the client step all the way to the front.
● The patient should push straight down on the handgrips of the walker
as they bring their good leg up so it is even with the injured leg. Assist
the patient as needed making sure the patient always takes small steps
when turning and moving slowly.
Sitting
● To sit:
- Back up until the patient’s legs touch the chair.
- Assist the client’s positioning making sure they are in line with
the seat of the chair then slowly lower them into the chair.
- Slowly lower the patient into the chair.
● To stand up:
- Assist the client in pushing themselves up using the strength of
their arms and grasp the walker's handgrips.
- Inform the client not to pull on or tilt the walker to help them
stand up.
56