CHAPTER ONE
NURSING CARE OF PATIENTS WITH URINARY PROBLEMS
INTRAVENOUS PYELOGRAM
Is the intravenous introduction of a radiopaque contrast medium that concentrates in the urine
and thus facilitates visualization of the kidneys, ureter, and bladder.The contrast medium is
cleared from the bloodstream by renal excretion
Patient with significantly decreased renal function should not have IVP because contrast media
can be nephrotoxic and worsen renal function.
Indications
-An intravenous pyelogram is used to determine the size, and shape of the kidney, bladder,
ureters and to determine whether they are functioning properly.
-It is recommended when a patient experience signs & symptoms such as pain in the sides, or
back or blood in urine that may be related to urinary tract disorders.
-It may be used to diagnose conditions such as Kidney stones,Bladder stones,Enlarged
prostate,Kidney cyst,Urinary tract tumors,Identifying certain structural urinary tract
disorders,Detecting kidney stones,infections of your bladder and kidney,bladder and kidney
stones,tumors,enlarged prostrate,abdominal injury,blockages in your urinary tract, urinary tract
obstruction etc.
CONTRAINDICATIONS
- renal failure,
- uncontrolled diabetes
- multiple myeloma
- creatine levels >1.6.
Before procedure
-Assess patient for iodine sensitivity to avoid anaphylactic reaction.
-Inform patient that procedure involves lying on table and having serial x-rays taken.
-Advise patient that during injection of contrast material, warmth, a flushed face, and a salty taste
may be experienced.
- Clear liquids only the day before the examination.
- Cathartics/laxatives are given the evening before the examination.
- Nothing by mouth (NPO) after midnight the day of the examination (if scheduled for afternoon,
clear liquids only in the morning).
After procedure
- give a lots of fluids (if permitted) to flush out contrast media.
CYSTOSCOPY
Cystoscopy is a method of direct visualization of the urethra and bladder by means of a
cystoscope that is inserted through the urethra into the bladder. It has a self-contained optical
lens system that provides a magnified, illuminated view of the bladder.
INDICATIONS
a. To inspect bladder wall directly for tumor, or ulcer and to inspect urethra for abnormalities or
to assess degree of prostatic obstruction.
b. To allow insertion of ureteral catheters for radiographic studies or before abdominal or GU
surgery.
1
c. To see configuration and position of ureteral orifices.
d. to obtain biopsy specimens of bladder lesions
e. To remove calculi from urethra, bladder, and ureter.
e. To diagnose and treat lesions of bladder, urethra, and prostate.
f. To perform endoscopic prostate surgeries including transurethral
resection of the prostate (TURP)
Contraindicated in patients with known UTI.
Lithotomy position is used. Procedure may be done using local or general anesthesia,
depending on patient’s needs and condition.
Before procedure
-
Explain the procedure to patient.
Ensure patient has signed consent form.
Give IV fluids if general anesthesia is to be used
Give preoperative medication e.g. Sedatives since it decrease the spasm of the bladder
sphincter.
After Care
 Explain that burning on urination, pink-tinged urine, and urinary frequency are expected
effects.
 Observe for bright red bleeding, which is not normal.
 Do not let patient walk alone immediately after procedure because orthostatic
hypotension may occur.
 Offer warm sitz baths, heat, mild analgesics to relieves discomfort
 Monitor for complications
 Expect patient to have some burning on voiding, blood tinged urine, and urinary
frequency from trauma to mucous membrane of the urethra.
 Administer antibiotics prophylacticallyas ordered, to prevent UTI.
 Increase hydration.
 Provide routine catheter care if urine retention persists and an indwelling catheter is
ordered.
Complications
-
urinary retention
urinary tract hemorrhage
perforation of the bladder
infection within prostate or bladder
2
URINARY CATHETERIZATION
It is the introduction of a rubber tube (catheter) into the bladder through the urethral orifice to drain
out urine. Catheterization may be done to relieve acute or chronic urinary retention, to drain urine
preoperatively and postoperatively, to determine the amount of residual urine after voiding, or to
determine accurate measurement of urinary drainage in critically ill patients
It is usually performed only, when necessary, because of the risk of introduction of
microorganisms into the bladder.
Catheters are commonly made of rubber or plastics although they may be made from latex,
silicone, or polyvinyl chloride (PVC).
They are sized by the diameter of the lumen using French (Fr) scale: the larger the number, the
larger the lumen. Antimicrobial-impregnated or hydrogel/silver-coated catheters may also be used
to reduce the risk of infection.
Plastic catheters are used for short periods only (eg. 1 week or less), because they are inflexible.
Latex may be used for patient with no known latex allergy. However, because of these allergies,
latex is being phased out of health care products.
Silicone catheters are used for long-term use (e.g. 2 to 3 months) because they create less
encrustation at the urethral meatus. However, they are expensive.
PVC catheter is used for 4 to 6 week periods. They soften at body temperature and conform to
the urethra.
Determine appropriate catheter length by the patient’s gender. For adult female patient, use a 22cm catheter; for adult male patients, a 40-cm catheter. Determine appropriate catheter size by the
size of the urethral anal. Use sizes such as #8 or #10 for children, #14 or #16 for adults. Men
frequently require a larger size than women, for example #18. Select the appropriate balloon size.
For adults, use a 10-ml balloon to facilitate optimal urine drainage. The smaller balloons allow
more complete bladder emptying because the catheter tip is closer to the urethral opening is the
bladder. However, a 30-ml balloon is commonly used to achieve hemostatsis of the prostatic area
following a prostatectomy. Use 3-ml balloons for children.
3
Indications
1. To reduce pain in urinary retention
2. To collect a sterile urine for investigations (urinalysis)
3. To maintain the patency of the urethra
4. To apply or administer medication
5. Determine the amount of residual urine in the bladder
6. Irrigate the bladder or to perform bladder lavage
7. To keep perineal area dry to promote healing
8. To determine accurate urinary output
9. For investigation of the lower urinary tract e.g. urodynia (pain during micturation)
10. To maintain comfort for patient with urinary incontinence and the terminally ill.
11. Before and after surgical procedures
Contraindications
1.
2.
3.
4.
Urethral strictures
Prostate enlargement
Urethritis
Client who are allergic to the silicon or latex rubber or the antiseptic solution
Complications
1.
2.
3.
4.
5.
Infections
Haemorrhage
Injury to the urethra
Pain
Urethra Strictures – following damage to the urethra –long term problem
Types of urinary catheterization
1. Urethral catheterization: This involves passing the catheter through the urethral to the
bladder.
2. Supra-pubic catheterization: A supra-pubic catheter is inserted surgically through the
abdominal wall above the symphysis pubis into the urinary bladder. The physician inserts
the catheter using local anesthesia or during bladder or vaginal surgery. The catheter may
be secured in place with sutures if a retention balloon is not used and is then attached to a
closed drainage system. The supra-pubic catheter may be placed for temporary bladder
4
drainage until the client is able to resume normal voiding (eg. After urethral, bladder, or
vaginal surgery) or it may become a permanent device (e.g. urethral or pelvic trauma).
A supra-pubic catheterization is done when the urethra is damaged or blocked, or when a
person has a long-term condition and is unable to use an intermittent catheter. It is mostly
done for patients with prostate enlargement who are having urinary retention.
NB: Clients who have a flaccid bladder (weak, soft, and lax bladder muscles) may use
manual pressure on the bladder to promote bladder emptying. This is known as Crede's
maneuver or Crede's method
URINARY CATHETERS
A urinary catheter is a tube inserted into the bladder to drain urine.
Types of urethra catheter
1. Self-retaining /Indwelling:Is a double lumen catheter. The larger lumen drains urine from
the bladder. A second, smaller lumen is used to inflate a balloon near the tip of the catheter
to hold the catheter in place within the bladder. Clients who require continuous or
intermittent bladder irrigation may have a three-way Foley catheter. The three-way catheter
has a third lumen through which sterile irrigating fluid can flow into the bladder. The fluid
then exists the bladder through the drainage lumen, along with the urine. Eg. Mushroom
tip, four-wing tip, 2 way and 3 way foley’s catheter.
2. Intermittent catheter: Intermittent catheter (straighter that drains bladder for a short
period). The straight catheter is a single-lumen tube with a small eye or opening about 1
1/4cm (1/2 in) from the insertion tip. The coude catheter is a variation of the straight
catheter. It is more rigid than other straight catheters and has tapered, curved tip. This
catheter may be used for men with prostatic hypertrophy because it is more easily
controlled and less traumatic on insertion. Examples, solid tip, hollow tip, whittle tip, hole
in tip.
3. The Condom catheter; The application of a condom or external catheter connected to a
urinary drainage system can be used for incontinent males. Use of a condom appliance is
preferable to insertion of a retention catheter because the risk of urinary tract infection is
minimal.
5
INSERTION OF INDWELLING CATHETER
Requirement
Top shelf (sterile)
1. Sterile fenestrated drape/ towel
2. Sterile gloves
3. Sterile receiver for cleansing lotion
4. Sterile gallipot with cotton wool swabs
5. Sterile artery forceps
6. 20mls syringe filled with 5-10mls of normal saline
Bottom shelf:
1. Various catheters of different sizes,
a. 14 and 16 for females,
2.
b.
18 and 20 for males,
c.
8 and 10 for a child.
Recommended lubricant eg K.Y jelly
3. Antiseptic cleansing lotion, diluted savlon
4. Receiver for used swab
5. Mackintosh and towel
6. Spigot
7. Drainage bag (urine bag)
8.
Normal saline
9. Specimen bottle where needed
10. A pair of scissors for plaster.
11. Bedpan, jug of warm water, soap and towel
Procedure / steps (Male)
1. Explain procedure to patient and provide privacy
2. Prepare and send trolley to patient bed side
3. Turn down top sheet and put patient in dorsal position.
6
4. Wash hands dry and put sterile gloves
5. Place sterile receiver in between flexed thighs of patient.
6. Clean the glands penis with suitable antiseptic lotion
7. Lubricate catheter with the help of an assistance
8. Hold the penis 90 degree and insert catheter about 25cm
9. Direct urinary outflow into receiver and inflate balloon
10. Connect catheter to urine bag, hang to bed and secure in position
11. Observe and note colour and amount of urine
12. Make patient comfortable in bed and discard trolley
13. Wash hands and dry
14. Document procedure and report findings
Procedure / steps (Female)
1. Explains procedure to patient, provide privacy and ensures adequate lighting
2. Protects bed with mackintosh and towel
3. Washes and dries hand and puts on a sterile gloves
4. Instruct s assistant to place patient in the supine position with knees flexed and legs
separated.
5. Inserts bedpan under patient and washes perineum thoroughly with soap and water
6. Removes bedpan and drapes with a sterile towel
7. Removes the gloves, wears another sterile glove and cleans the vulva with an antiseptic
8. Lubricates catheter with xylocaine jelly.
9. Uses the non-dominant hand to part the labia and establishes a firm but gentle position.
10. Picks a cotton wool swab soaked in antiseptic with forceps in the dominant hand and swab
one side of the labia majora from top to bottom, uses a new ball for opposite side, uses new
swabs to clean one side labia minora in the same manner and the vestibule respectively.
11. Pass the tip of the catheter into the urethral orifice and then gently push it in an upward and
backward direction for about 5cm (2 inches) leaving the open end in the receiver between
the patient’s thighs.
12. Inflate the balloon of the catheter with sterile water according to manufacturer’s direction
13. Collect urine specimen if needed.
7
14. Connect catheter to urine bag, hang to bed and secure in position
15. Observe and note colour and amount of urine
16. Remove drapes and make patient comfortable in bed and discard trolley
17. Wash hands and dry
18. Document procedure and report findings
CAHTETER CARE (Catheter hygiene)
This is carried out whenever a self-retained catheter is in situ and the patient is unable to get into
the bath room. It is normally done during and after patient’s personal hygiene especially during
bed bath but it is a sterile procedure. The purpose is to prevent urinary tract infection that will lead
to complications like pain and to also prevent dirt from entering into the vulva and vagina. A selfretained catheter must be changed every 2 weeks or less if catheterization is for long term.
Requirement
Top shelf:
1. Sterile receiver containing sterile cotton wool or gauze swab
2. Sterile towels
3.
Sterile gallipot with normal saline
4. Sterile gallipot with diluted antiseptic lotion mostly savlon
5. Sterile receiver
6. Sterile glove
Bottom shelf:
1. Receiver for dirty dressing
2. Disposables gloves if needed
3. Mackintosh and towel
4. Receptacle for used towel
Procedure / Steps
Female
8
1. Establish rapport and explain procedure to patient
2. Assemblies necessary items
3. Provide privacy
4. Place mackintosh and towel under patient’s buttocks
5. Covers patient up so that only vulva area is exposed
6. Remove anchor device to free catheter tubing
7. Washes hands and puts on gloves
8. Places sterile towel beneath catheter
9. Cleans the vulva using cotton wool swabs and antiseptic lotion towards the anus
10. Swabs the urethral orifice, moving down the catheter
11. Repeats with series of swabs till orifice is clean.
12. Reassess urethral meatus for discharge
13. Use swabs soaked in antiseptic lotion to wipe in a circular motion along the length of
catheter and anchors back into position
14. Apply antibiotic ointment at the urethral meatus and along 2.5cm of catheter if ordered by
doctor
15. Place patient in a safe and comfortable position
16. Disposes all contaminated items, removes gloves and wash hands
17. Record and report findings.
Male
1. Establish rapport and explain procedure to patient
2. Assemblies necessary items
3. Provide privacy
4. Place mackintosh and towel under patient’s buttocks
5. Covers patient up so that only genital area is exposed
6. Remove anchor device to free catheter tubing
7. Washes hands and puts on gloves
8. Places sterile towel beneath catheter
9. Retract foreskin if present to expose urethral meatus, cleans around catheter first, and
then wipes in circular motion along the meatus and glans
9
10. Repeats with series of swabs till orifice is clean.
11. Reassess urethral meatus for discharge
12. Use swabs soaked in antiseptic lotion to wipe in a circular motion along the length of
catheter and anchors back into position
13. Apply antibiotic ointment at the urethral meatus and along 2.5cm of catheter if ordered
by doctor
14. Place patient in a safe and comfortable position
15. Disposes all contaminated items, removes gloves and wash hands
16. Record and report findings.
REMOVAL OF INDWELLING CATHETER
Requirement:
1. A tray containing sterile 20cc syringe
2.
Sterile Swabs
3. Sterile receiver
4. Makintosh and towel
5. Bowl
6. Specimen bottle
7. Sterile gloves
Procedure / steps
1. Explain procedure to the patient
2. Provide privacy
3. Fold back bed clothes and expose catheter
4. Place the mackintosh and towel under the buttocks
5. Wash and dry hands, wear gloves
6. Place a sterile towel on the mackintosh
7. Insert the 20cc syringe end into the balloon inlet of the catheter and withdraw the water
from the balloon. Do not use a needle.
8. Remove catheter gently and place it into a receiver. Place the drainage bag into the
bowl.
10
9. Dry genital area with towel
10. Measure urine in the drainage bag and remove gloves
11. Make patient comfortable in bed and thank him or her for cooperation.
12. Discard and decontaminate all equipment used if not disposable
13. Wash and dry hand and document findings
Dialysis
Dialysis refers to the diffusion of solute molecules through a semipermeable membrane, passing
from the side of higher concentration to that of lower concentration. The purpose of dialysis is to
maintain fluid, electrolyte, and acid-base balance and to remove endogenous and exogenous
toxins. It is a substitute for some kidney excretory functions but does replace the kidneys’
endocrine functions.
Indications
-Increased potassium levels (hyperkalemia)
-Uremia (high levels of urea in the blood)
-Renal failure (acute/chronic)
-Hypercalcemia
-Fluid overload
-Medication poisoning
-Increased ammonia levels
Types of dialysis
Peritoneal dialysis.
Hemodialysis
Continuous renal replacement therapy (CRRT)
1. Peritoneal dialysis.
a. Intermittent peritoneal dialysis (IPD).
b. Continuous ambulatory peritoneal dialysis (CAPD).
c. Continuous cycling peritoneal dialysis (CCPD)—uses automated peritoneal dialysis machine
overnight with prolonged dwell time during day.
Intermittent peritoneal dialysis
Is an option for treating acute kidney injury when access to the bloodstream is not possible or
hemodialysis/CRRT is not available. It also may be used in cases of poisoning, congestive heart
failure, or hypothermia. It is similar to CAPD in that it involves access to the peritoneal cavity,
either with a newly inserted rigid stylet catheter or, in chronic peritoneal patients, the existing
chronic catheter can be used. In IPD, an exchange ranges between 30 minutes and 2 hours.
Exchanges are repeated continuously for a prescribed period of time, which varies between 12
and 36 hours. Due to the rapid exchanges, patients are on bedrest. As with all peritoneal dialysis
procedures, aseptic technique is essential during catheter insertion, exchanges, and dressing
changes to prevent peritonitis.
Continuous ambulatory peritoneal dialysis (CAPD)- uses the peritoneum as the semipermeable
membrane
11
Continuous renal replacement therapy (CRRT) - Is indicated for hemodynamically unstable
patients who cannot tolerate the rapid fluid shifts that occur with intermittent dialysis and in
oliguric patients who require large amounts of hourly IV fluids or parenteral nutrition.
CRRT is often better tolerated by critically ill patients because it is a slower and less aggressive
process for removal of fluid and solute than haemodialysis
PERITONEAL DIALYSIS PROCEDURE
Preparation of the patient
Preparation of the equipment
Inserting the catheter
Infusion exchange (dialysis cycle)
PREPARING THE PATIENT
-
The nurse explains the procedure to the patient and family and assist in obtaining
assigned consent form.
Check base line vital signs, weight and serum electrolyte levels and record.
Evaluate the abdomen for the catheter placement to facilitate self-care. Typically, the
catheter is placed on the non dominant side to allow the patient easier access to the
catheter connection site when exchanges are done.
PREPARATION OF THE EQUIPMENT
1.Consults the physician to determine the concentration of dialysate to be used and the
medication to be added to it. Heparin may be added to prevent fibrin formation, Potassium
chloride to prevent hypokalaemia, antibiotics to prevent peritoneal infection, regular insulin may
be added for patients with diabetes.
2. Before the medications are added, warm the dialysate to body temperature to prevent patient
discomfort and to dilate the vessels of the peritoneum to increase urea clearance. Solutions that
are too cold cause pain, cramping and vasoconstriction and reduce clearance.
3.The solution can be warmed by dry heating (heating cabinet, incubator or heating pad).
4.Do not warm solution by soaking it in a warm water because, this can introduce bacteria to the
exterior of the bag and increase the chance of peritonitis.
5.Do not use a microwave to heat the solution, this increases the danger of burning the
peritoneum
6. Assemble the administration set and tubing and expel air from the tubing
12
INFUSION EXCHANGE (DIALYSIS CYCLE)
This involves three phases
Infusion/instillation phase: the dialysate is infused into the peritoneal cavity by gravity. This
requires about 5-10 minutes to infuse 2 liters of dialysate into the cavity
Equilibration/ Dwell phase: during this phase, diffusion and osmosis occur between the
patient’s blood and peritoneal cavity. The duration of dwell time can last 20 to 30 minutes to 8 or
more hours depending on the method of peritoneal dialysis
Drain phase: The drainage portion of the exchange begins. The tube is unclamped and the
solution drains from the peritoneal cavity by gravity through a closed system. Drainage is usually
completed in 10 to 20 minutes. The drainage fluid is normally colorless or straw-colored and
should not be cloudy. Bloody drainage may be seen in the first few exchanges after insertion of a
new catheter but should not occur after that time.
The cycle starts again with the infusion of another 2L of solution
ADVANTAGES OF PERITONEAL DIALYSIS
-
Low cost
Can be done immediately anytime anywhere
No blood loss during the process
No risk of heparin reaction recorded because small /no heparin is used
No interruption of daily activities
Complications
a. Infectious peritonitis
b. catheter obstruction
c. Dialysate leak.
d. Peritoneal–pleural communication, hernia formation
e. GI bloating, distention, nausea.
f. Hypervolemia
g. Bleeding at catheter site.
Patient education
Diet: advice patient to take high protein diet, low sodium, and avoid high phosphorus
diets such as dried beans, liver, cheese.
.
HEMODIALYSIS
-
Is a process that uses a manmade membrane (dialyzer) to remove wasters, such as urea
from the blood, Restore the proper balance of electrolytes in the blood, and eliminate
extra fluid from the body.During hemodialysis, the patient is connected to a fitter
(dialyzer) by tubes attached to the blood vessels. Blood is slowly pumped from the body
13
-
in to the dialyzer, where waste products and extra fluids are removed. The filtered blood
is then pumped back in to the patient’s body.
Hemodialysis may improve the quality of life of patients and increase their life
expectancy. It provides only about 10% of normal kidney function but it does not reverse
chronic kidney disease or kidney failure. It may be used when fluid and electrolyte
problem are causing severe symptoms or other problems.
TYPES OF HEMODIALYSIS
a) In-center hemodialysis: The patient goes to the hospital or dialysis centre for treatment
session. This is done 3 days in a week and takes 3 to 5 hours a day.
b) Home dialysis: This is done at home after proper training and is usually done 3 days a
week (every other day. A session should be as long as 6 hours).
c) Daily home hemodialysis: This is done 5 to 7 days in a week after the patient is trained.
Each session takes about 3 hours.
d) Nocturnal home hemodialysis: Is done 3 to 7 night, in a week. Each session is done
overnight (about 6 to 8 hours).
Indications
Hemodialysis is often started after symptoms or complications of kidney failure develop such as:
a. Signs of uremic syndrome, such as nausea, vomiting loss of appetite and fatigue
b. High levels of potassium in the blood (hyperkalaemia)
c. Signs of the kidney’s inability to clear the body’s daily excess fluid intake, such as
swelling.
d. High levels of acid in the blood (acidosis)
e. Pericarditis
Requirements for Hemodialysis
1.
2.
3.
4.
5.
Access to patient’s circulation.
Dialysis machine and dialyzer with semipermeable membrane.
Appropriate dialysate bath.
Time—approximately 4 hours, three times weekly.
Place—dialysis center or home (if feasible).
Methods of Circulatory Access
1. Arteriovenous fistula (AVF)—creation of a vascular communication by suturing a vein
directly to an artery
2. Arteriovenous graft—arteriovenous connection consisting of a tube
3. Central vein catheters—direct cannulation of veins (subclavian, internal jugular, or femoral);
may be used as temporary or permanent dialysis access.
Complications of Vascular Access
14
1. Infection.
2. Catheter clotting.
3. Central vein thrombosis or stricture
Complications of Vascular Access
1.
2.
3.
4.
Infection.
Catheter clotting.
Central vein thrombosis or stricture
Stenosis or thrombosis
Procedure for Hemodialysis
-
Patients circulation is accessed
Unless contraindicated, Heparin is administered to prevent blood clot formation.
Dialysis solution surrounds the membrane and flows in the opposite direction.
Dialysis solution is a highly purified water, contains sodium, potassium, calcium,
magnesium, chloride and dextrose. It is either bicarbonate or acetate to maintain a proper
pH.
Through the process of diffusion, wastes are removed in the form of solutes (metabolic
wastes, acid, base components and electrolytes) and discarded.
Ultrafiltration removes excess water from the blood
After cleansing the blood returns to the client via the access point.
-
Nursing Interventions for Hemodialysis
1.
2.
3.
4.
5.
Explain the procedure to patient and relatives
Monitor hemodynamic status continuously
Monitor acid-base balance and electrolytes
Maintain a closed system and sterility of the system
Discuss diet and dietary restrictions with patient on: sodium, potassium, protein and
Fluid intake
6. Reinforce adjustment to prescribed medications that may be affected by the process of
hemodialysis.
Nursing Care of Patient Undergoing Hemodialysis
PRE DIALYSIS CARE

Monitor patient’s vital signs including the orthostatic blood pressure, apical pulse and
lung sounds. These data help provide base line information to help evaluate the effects of
hemodialysis. Hypertension may indicate excess fluid volume. The client who is
15





hypotensive may not tolerate rapid fluid volume changes during dialysis. Abnormal heart
sounds (e.g. a gallop, murmur) and change in heart rate or rhythm may indicate excess
fluid volume or electrolyte in balance. Fluid overload may also cause dyspnoea,
tachypnea and crackles in the lungs.
Record patient’s weight. Changes in weight is an effective indicator of fluid volume
increase.
Assess vascular access site for a palpable pulsation or vibration and an audible bruit and
for inflammation. Infection and thrombus formation are the most common problems of
the access site in hemodialysis clients.
Alert all staff to avoid using the affected extremity with the vascular access site for blood
pressure monitoring or venipuncture. These procedures may damage vessels and lead to
failure of the AV fistula.
Explain procedure to the patient and reassure him/her
Put patient in the required position and support them.
Intraprocedure Care
-
Monitor vital signs every 15 minutes initially and subsequently at an hour intervals.
Notify the physician if any sign of bleeding, severe abdominal pain and respiratory
distress.
Use strict aseptic technique to avoid infection.
Assess patient frequently for pain/discomfort.
Post Dialysis Care




Assess and document vital signs, weight and vascular access site condition. Rapid
fluid and solute removal during dialysis may lead to orthostatic hypotension,
cardiopulmonary changes and weight loss.
Monitor BUN, serum creatinine, serum electrolyte, and haematocrit levels between
dialysis treatments. These values help determine the effectiveness of the treatment,
the need for fluid and diet restrictions and the timing of future dialysis sessions. The
anemia associated with renal failure does not improve with dialysis, and iron and
folate supplements or periodic blood transfusions may be needed.
Assess for dialysis disequilibrium syndrome, with headache, nausea and vomiting,
altered level of consciousness, and hypertension. Rapid changes in BUN, pH and
electrolyte levels during dialysis may lead to cerebral edema and increased
intracranial pressure.
Assess for other adverse reactions to dialysis, such as dehydration, nausea and
vomiting, muscle cramps, seizure. Excess fluid removal and rapid changes in
electrolyte balance can cause fluid deficit, nausea, vomiting and seizures.
16

-
Assess for bleeding at the access site or elsewhere. Renal failure and use of heparin
during dialysis increase the risk of bleeding. Frequent exposure to blood and blood
products increase the risk for hepatitis B or C other blood borne diseases.
 If a transfusion is given during dialysis, monitor for possible signs of transfusion
reaction (e.g. chills, fever, chest, back or arm pinching or urticaria rash. Clients with
renal failure may receive multiple transfusions, increasing the risk of transfusion
reaction. Close monitoring during and after the transfusion is important to identify
early signs of a reaction.
 Provide psychological support and listen to patients. Refer client to social services
and counselling.
 Monitor for complications of dialysis such as:
Arteriosclerotic cardiovascular disease
Congestive heart failure
Stroke,
Infection, Hypertension
Calcium deficiencies
Depression, sexual dysfunction etc
Complications
a.
b.
c.
d.
e.
f.
g.
h.
Low blood pressure (hypotension).
Muscle cramps.
Irregular heart beat (arrhythmia)
Nausea, vomiting, headache or confusion due to dialysis disequilibrium.
Blood clot (thrombus) formation in the venous access catheter.
Infection.
Technical complications, such as trapped air (embolus) in the dialysis tube.
Anaemia
Long term complications may include:
a. Inadequate filtering of waste products (hemodialysis inadequacy).
b. Thrombus formation in the dialysis graft or fistula
c. Cardiovascular disease (heart disease, blood vessel disease, or stroke)
CHAPTER TWO
NURSING MANAGEMENT OF PATIENTS WITH CARDIOVASCULAR
CONDITIONS
CARDIAC CATHETERIZATION
Cardiac catheterization is a diagnostic procedure in which a catheter is introduced into
the heart and blood vessels. The access site of choice is the femoral vein
17
INDICATIONS
- to provide physiologic data to guide treatment
- to measure cardiovascular hemodynamics
- to acquire radiographic images of coronary arteries, cardiac chambers, and aorta
- to collect blood from various chambers for analysis
- to evaluate pulmonary blood flow and shunts.
TYPES
Left side catheterization
The catheter is passed through the femoral artery to the external iliac artery, common iliac artery,
abdominal aorta, thoracic aorta, descending aorta, aortic arch then to the ascending aorta. From
here the heart can be accessed.
Right side catheterization
The right side of the heart can be accessed either through the subclavian vein in the clavicular
region or the jugular vein in the neck ,cephalic vein in the arm to the brachiocephalic vein to the
superior vena cava .The right side of the heart can be accessed from here. Swan-Ganz catheter is
used for right catheterization.
Requirement
Swan-Ganz catheter,Sterile gown for the radiologist,Sterile gloves,Mask,Goggles,Intravenous
equipments for I.V set up,ECG investigation done,IV sedatives eg, I.V midazalam,
diazepam,Oxygen resuscitative equipment, pulse oxymeter
Before procedure
1. Explain procedure to patient and tell patient that he or she will be lying on an
examination table for a prolonged period and may experience certain sensations such as
thudding sensations in the chest, Strong desire to cough, Transient feeling of hot flashes
or nausea
2. Obtain an informed consent if needed by the hospital.
3. Assess patient for allergy of iodine or shell fish or sea foods
4. Tell patient to fast for at least 4-8 hours before the test.
5. Make sure laboratory testing has been ordered and results reviewed, including
BUN/creatinine, to evaluate kidney function for ability to clear contrast dye;
hemoglobin/hematocrit; platelet count and coagulation values, to ensure clotting and
anticoagulation baseline; WBC count, to rule out infection that may be exacerbated by
invasive procedure; electrolytes; and blood type and screen, in case blood transfusion is
necessary.
6. Make sure baseline ECG is documented
7. Ensure IV patency for administration of medications
8. Tell patient to void before the procedure
18
9. Allow for premedication (if any) to take effect prior to procedure.
Postprocedure
1. Monitor vital signs
2. Check for bleeding or hematoma formation at insertion site.
3. Check distal extremity for normal color and intact pulses, and evaluate complaints of pain,
numbness, or tingling sensation to determine signs of arterial insufficiency.
4. Assess for complaints of chest pain and respond immediately.
5. Evaluate complaints of back, thigh, or groin pain (may indicate retroperitoneal bleeding).
7. Obtain postprocedure ECG and labs
8. Assess urine output and note the colour and amount of urine and document
9. Encourage patient to drink plenty of liquids to clear the contrast material from the body
10. Instruct patient to report any bleeding or any feeling numbness, tingling in the fingers or
bleeding
11. Maintain an hourly intake and output chart
Echocardiography (Ultrasound Cardiography)
Echocardiography is a test that uses sound waves to create pictures of the heart.it is used to
visualize and assess cardiac function, structure, and hemodynamic abnormalities. It is the most
commonly used noninvasive cardiac imaging tool
Indications
1. detection of valvular and other structural deformities
2. detection of pericardial effusion
3. evaluation of prosthetic valve function
4. diagnosis of cardiac tumors,cardiomegaly (heart enlargement), clots, vegetations on
valves
Types echocardiography
1. 2-D echocardiography—provides a wider view of the heart and its structures because it
involves a planar ultrasound beam.
2. M-mode—utilizes a single ultrasound beam and provides a narrow segmental view.
3. Doppler mode—evaluates pressures and blood flow across the valves; also assesses for
atrial and ventricular septal defects.
Nursing Care
1. Advise patient that traditional echocardiography is noninvasive and that no preparation is
necessary.
2. Position patient on left side, if tolerated, to bring the heart closer to the chest wall.
3. Assist patient to clean chest of transducer gel after the test.
Electrocardiography
An electrocardiography is a technique where electrical activity of the heart is recorded over a
period of time using electrodes placed on the skin of the four limbs and chest wall. It is quick,
simple, painless test that checks for problems with the electrical activity of the heart and also
monitors the heartbeat. It is also known as an ECG or EKG
Indications
19
ECG is a useful tool in the diagnosis of conditions that may cause aberrations in the electrical
activity of the heart.Examples of these conditions include:
a. MI and other types of CAD such as angina.
b. Cardiac dysrhythmias.
c. Cardiac enlargement.
d. Electrolyte disturbances (calcium, potassium, magnesium, and phosphorous).
e. Inflammatory diseases of the heart.
f. Effects on the heart by drugs, such as antiarrhythmics and tricyclic antidepressants.
Preparation for the procedure
 Explain procedure to the patient/family and the need to lie still, relax and breath normally
during the test.
 Explain that the test is painless and takes about 5-10 minutes
 Instruct patient to lie still, avoiding movement, coughing, or talking, while ECG is
recording to avoid artifact
 Assist patient to remove all jewelry and dentures as well as clothing above the waist
 Tell patient not to apply skin cream (pomade) to prevent its interference with obtaining
good ECG results.
 Assist patient to wear a gown and lie comfortably in a supine position on the examination
table.
 Provide privacy
 Expose the arms and legs and chest. Shave the areas if hairy and clean with alcohol for
proper electrode adhesion
 Check vital signs
 Tell patient to avoid drinking cold water or exercising before EKG test. Drinking cold
water can cause changes in the electrical patterns that the test records. Exercise can
increase the heart rate and affect the test results.
 Assess the patient for their medications including over-the-counter drugs. Because many
medications can change the results of this test
 Obtain a signed consent form
Procedure





Put patient in the required position on a bed or table.
Shave and clean the parts of the body that will be used. Such as the arms, legs, and chest.
This provides a clean, smooth surface to attach the electrodes.
Several electrodes are attached to the skin on each arm and leg and on the chest. These
are hooked to a machine that traces the heart activity onto a paper. The electrodes may be
moved at different times during the test. This measures the heart's electrical activity from
different places on the chest.
Encourage patient to lie very still and breathe normally during the test. Though
sometimes the patient may be asked to hold his breath. Also ask patient not to talk during
the test.
After the test, wiped off the electrode paste. The test usually takes 5 to 10 minutes.
20
AFTER THE PROCEDURE
 Help the patient to dress up
 Check and record vital signs
 Patient should be able to resume normal diet and activities
 Notify the physician if the patient develops any sign/symptoms such as chest pain,
shortness of breath, dizziness after the procedure
COMPLICATIONS




Cardiac arrhythmias (abnormal heart beat)
Breathing difficulties such as wheezing, shortness of breath
Chest pain or angina
Skin rash, swelling and redness where electrodes were placed, but this usually goes away
without treatment.
POSITIONING OF PATIENT WITH CARDIAC PROBLEMS

The position that the patient with decreased cardiac output finds most comfortable in bed,
may be determined by his/her breathing.

If the patient is experiencing a profound decreased in cardiac output, with little dyspnoea,
the supine position is preferable. This position facilitates venous returns to the heart and
reduces the heart workload.

The patient who is experiencing sever dyspenoea, will be more comfortable with the head
of the bed elevated, but the height of the elevation should only be that at which the
dyspnoea is minimal.

Patient may manifest orthopnoea that is less difficulty in breathing with the lung in the
upright position. This position increases vital capacity and tends to reduce the volume of
blood returned to the heart and the pulmonary system. Pressure of abdominal viscera on
the diaphragm is reduced.

A special cardiac bed on which the foot of the bed can be lowered to provide a chair-like
support is available. Alternatively, the patient may find comfort from sitting in a chair.

The sitting position promotes the formation of peripheral oedema in the dependent parts,
but relieves the pulmonary congestions to some extent; peripheral oedema is much less
serious than pulmonary oedema.

In the sitting position, a pillow place longitudinally at the patient’s back may help provide
some comfort. Pillows should be used at the sides to support the arms and relieved the
21
fatiguing pull on the shoulders. A change may be effected by arranging a table and pillow
over the bed, upon which the patient may rest the head and arms.

Cot sides may be kept up on the bed to save guide the patient when in the upright position,
as the patient may become drowsy and fall to the side, or may experience cerebral hypoxia,
which causes disorientation. The sides are also useful when a change of position is made
because they may be grasped by the patient and used for added support.

Patients in the upright position are encouraged to assume the recumbent position for
periods to help reduce circulatory stasis and oedema in the lower part of the body.
However, patients should not be force to do this, if they are suffering from severe dyspnoea.

In patients with heart conditions, as with all patients, the general principles of positioning
apply.

Good body alignment is respected to prevent contractures hyper-extension and circulatory
stasis. Even a slight change in position every one to two hours is helpful. A footboard is
used to prevent foot drop.

Constipation should be prevented and the patient cautioned against straining at stools,
because of the stress it places on the heart. A mild laxative or stool softener may be given
as necessary.
CHAPTER THREE
NURSING CARE OF PATIENTS WITH RESPIRATORY PROBLEMS
THORACENTESIS
Thoracentesis is an invasive procedure that entails insertion of a needle into the pleural space for
removal of fluid (or rarely) air.
Pleural fluid is removed for diagnostic and therapeutic purposes.
Purposes
1. To make diagnosis or diagnostic purposes. Thoracentesis is performed to obtain and analyse
fluid to determine the cause of the pleural effusion.
Pleural fluid is classified as transudate or exudates. It is an important dysfunction and is very
helpful in determining the cause of effusion. Transudate fluid appears clear and thin fluid whiles
exudates is thick cloudy.
22
Transudates are most frequently caused by congestive heart failure, cirrhosis, nephrotic
syndrome and hypoproteinemia.
Exudates are most often found in inflammatory infections or neoplastic conditions.
2. Therapeutically, it is done to relieve symptoms of pain, dyspnoea, and other
Symptoms of pleural pressure.
3. For radiographic visualization of the lung. Removal of this fluid also permits better
radiographic visualization of the lung.
4. To remove excess fluid so to prevent infection and subsequent complications such as
empyema, respiratory distress and pulmonary compression.
5. To administer medication. Some medication are instilled into the thoracic cavity, example is
chemotherapeutic agents.
Indications of Thoracentesis
 emphysema
 Empyema
 To introduce medication
 Pneumonia
 Pulmonary effusion
 Congestive heart failure
Contraindication
- Uncertain fluid location by examination
- Minimal fluid volume
- Altered chest wall anatomy
- Pulmonary diseases
- Bleeding disoders or coagulopathy
- Uncontrolled coughing
- Patients with significant thrombocytopenia. This is because the aspirating needle may
initiate bleeding.
The Site of Thoracentesis
The common site for thoracentesis or pleural aspiration is the area just below the inferior angle
of the scapular at the seventh intercostal space. The lower level of the scapular is used as a
landmark and then, the distance of the fluid below this landmark is measured.
Position of the Patient
1. It is performed with the patient sitting upright with the arms and shoulders raised. The upright
position helps accumulate the pleural fluid at the base of the chest from where it can be removed.
Due to elevation of Shoulders and arms, the ribs are elevated and separated so that insertion of
the needle becomes less traumatic.
2. If the patient is too ill to maintain an upright Position, turn the patient onto the unaffected side
and place the arm on the affected side over the head.
23
Requirements
A sterile tray containing
Sponge holding forceps.
Thoracentesis aspiration needles
5ml syringe and needles for local anaesthesia.
Gauge needles (large and short).
2 gallipots for cleansing lotion
Dissecting forceps.
50m1 syringe with lever lock to aspirate fluid.
3-way adaptor with tubing.
 Drape Gown, mask and gloves for the doctor.
 Dressing materials — cotton wool
 Sterile dressing towel, shaving razor swabs, gauze etc.
 Request forms and specimen bottle.
Unsterile tray Containing
1. Lidocaine
2. Methylated spirit, iodine povidone.
3. Mackintosh and towel.
4. Kidney dish and paper bag.
5. Suction machine with water seal drainage system. It is used when the pleural fluid cannot be
drained by gravity.
General Instructions
1. Prepare the patient physically and psychologically for the procedure. Give him adequate
explanations about the procedure to win his confidence and get his cooperation.
Explain the procedure to his relatives also.
2. tell the patient that any sudden movement during the procedure can cause injury to lungs,
blood vessels etc. So, remind him not to move or cough during the procedure. It coughing is
unavoidable the doctor may withdraw the needle temporarily to prevent injury to lungs.
3. Use short needle to prevent prickling of the lungs.
4. A cough suppressant may be needed if the patient has a troublesome cough.
5. An x-ray film, ultrasound scan, or fluoroscopic view is used to assist in localizing the pleural
fluid and in determining the needle insertion site.
6. The three-way adaptor should be filtered with the needle before it is introduced into the chest
cavity, it should be in a closed position so that air will not enter into the pleural cavity.
The needle is introduced above the level of the 9th intercostal space so that the diaphragm may
not be pierced and injury to liver and other abdominal organs is prevented.
7. The syringes and needles should be air tight because entry of air into the pleural cavity causes
collapse of lungs.
8. About l000mls of fluid is withdrawn slowly at a time during the first 30minutes
When a large amount of fluid is withdrawn rapidly, it causes circulatory failure or cardiac failure
due to shifting of mediastinum. Rapid removal does not provide sufficient time for the lung to reexpand and it results in re-accumulation of fluid in pleural cavity (negative intrapleural pressure
leading to oedema).
Sudden shifting of the fluid into the pleural cavity will cause shock and collapse and cardiac
failure in the patient.
9. Observe pulse, respiration and colour of the patient to detect early signs of complication.
24
10. Maintain aseptic techniques to prevent introduction of infection into pleural cavity.
11. If there is respiratory distress, excessive coughing, sharp pain haemoptysis or circulatory
collapse, stop aspirations immediately.
12. If the clients are purulent and it is very difficult to drain use closed water seal drainage.
13. Chest x-rays examinations are done after this procedure to check for pneumothorax.
Procedure and Patients Care
Before
1. Explain procedure to patient.
2. Obtain informed consent for the procedure.
3. Tell the patient that no fasting or sedation is necessary.
4. Inform the patient that movement or coughing should be minimized to avoid inadvertent
needle damage to the lung or pleura during the procedure.
5. Administer a cough suppressant before the procedure if the patient has a troublesome cough.
Note that an x-ray film or ultrasound Scan is often used to assist in location of the fluid.
During
1. The patient is usually placed in an upright position with arms and shoulders raised
and supported on a padded overhead table. This position spreads the ribs and enlarges the
intercostal space for insertion of the needle.
2. Patient who cannot sit upright are placed in a side lying position on the unaffected
side with the side to be tapped uppermost.
3. The thoracentesis is performed under strict aseptic technique.
4. The needle insertion site is aseptically cleansed and anaesthetized locally.
5. The needle is positioned in the pleural space, and the fluid is withdrawn with a syringe and a
three way adaptor or stopcock.
6. The needle is withdrawn and the soft plastic catheter is left in place. The fluid is aspirated. The
use of these soft catheters have greatly diminished the incidence of pneumothorax as a
complication.
(Various mechanisms to stabilize the pleural needle or catheter are available to secure the needle
depth during the fluid collection).
Observe the client for signs of distress such as dyspnea, pallor and coughing
Monitor the patients pulse for reflex bradycardia and evaluate the patient for diaphoresis and the
feeling of faintness during the procedure.
After
1. Place small gauze over the needle site. Usually turn the patient on the unaffected side
with the head of the bed elevated 30degrees for at least 30 minutes because this position
facilitate expansion of the affected lung and eases respiration.
N.B Do not remove more than 1000ml of fluid from the pleural cavity within the first 30
minutes
2. Label the specimen correctly with the patient’s name, date, source of fluid, and
diagnosis
4. All test done or pleural fluid should be performed immediately to avoid false results caused by
chemical or cellular deterioration.
5. Perform a chest x-ray to check for pneumothorax complications.
6. Monitor the patient’s vital signs especially pulse and respiratory rate
Observe changes in patients’ skin, cough, sputum, respiratory depth and breath sounds and note
if patient complains of chest pains skin for any colour change
25
7.Observe patient for signs and symptoms of pneumothorax , dyspnea, and emphysema
diminished breath sounds, anxiety, restlessness and fever.
8.Assess the patient’s lung sounds for diminished breath sound which could be a sign of
pneumothorax
9.Observe the chest movement and compare chest movement on both sides.
10.Check puncture site for leakage of fluid.
11.Check site for swelling, redness which may indicate signs of infection
12.Maintain intake and output chart
13.Keep punctured site dry and treat it with aseptic technique to prevent infection.
14.Ask the patient to do deep breathing exercises that will help expansion of lungs.
15.Send the aspirated fluid to the laboratory after proper labeling.
16.Clean, dry and send the articles for autoclaving.
17. Wash and dry hands.
18.Record your findings..
Complications
1. Pneumothorax caused by puncture of the lungs or entry of air into the pleural space
through the aspiratory needle.
2. Intrapleural bleeding caused by puncture of a blood vessel.
3. Haemoptysis caused by a needle puncture of a pulmonary vessel
4. Pulmonary edema
5. Empyema caused by infection delivered by the aspirating needle
6. Pain
UNDER WATER SEAL DRAINAGE
Water seal drainage system is a closed chest drainage system used to allow air and fluid to
escape from the pleural space with each exhalation and to prevent their reflux or back flow with
each inhalation. Water seal means that the water in the bottle seals off the atmospheric air thus
preventing the entry of air or fluid back into the pleural space.
INDICATIONS
1. Traumatic pneumothorax
2. Hemopneumothorax
3. Spontaneous pneumothorax
4. Iatrogenic pneumothorax
5. Broncho-pleural fistula
6. Emphysema
26
7. Malignancy
8. Pleural effusion
9. Thoracic or thoraco-abdominal surgeries
Contraindications
a. Coagulopathy
b. Diaphragmatic hernia
c. Scaring of the pleural space
PURPOSES
-
To permit drainage of air and fluid from the pleural cavity
Therapeutic treatment e.g. removal of pus and instillation of antibiotics into the pleural
space
To establish normal negative pressure in the pleural cavity for lung expansion
To equalize pressure on both sides of the thoracic cavity
To provide continuous suction to prevent tension pneumothorax
Diagnosis purposes
To relief pulmonary compression
Facilitate easy breathing or respiration
Site for chest tube insertion
In thoracic surgery: Two chest tubes are inserted – Anterior chest tube and Posterior
chest tube. Anterior chest tube: is inserted in the Upper/anterior chest wall in the 2nd
Intercostal space to remove the air arising from the pleural cavity.
Posterior chest tube: Placed at the posterior chest in the 8th or 9th Intercostal space at
the mid-Axillary line. Indication is to remove sero-sangeneous fluid at the lower area of
pleural cavity. Diameter of tube in the lower section is wider or longer as compared to the
upper tube.
In pneumothorax: the tube is placed at the 2nd or 3rd Intercostal space along the midclavicle or anterior Axillary line.
TYPES OF SYSTEM
 1 bottle drainage system
 2 bottle drainage system
 3 bottle drainage system
27
The Single-Bottle Water-Seal System.
(1) Connecting or drainage tubing joins the patient's chest tube with a drainage tube (glass rod)
that enters the drainage bottle.
(2) The end of the glass rod is submerged in water, extending about 2.5 cm (1 inch) below the
water level.
(3) The water seal permits drainage of air and fluid from the pleural space but does not allow air
to reenter the chest.
(4) Drainage depends upon gravity, the mechanism of respiration, and, if ordered, the addition of
controlled suction.
(5) The second tube in the drainage bottle is a vent for the escape of any air drained from the
lung. If suction is ordered, it is attached here.
(6) Bubbling at the end of the drainage tube may or may not be visible. Bubbling may mean
persistent air leaking from the lung or a leak in the system.
(7) The water level in the bottle fluctuates as the patient breathes. It rises when the patient
inhales and lowers when the patient exhales.
(8) Since fluid drains into this bottle, be certain to mark the water level prior to opening the
system to the patient. This will allow correct measurement of patient drainage.
The Two-Bottle Water-Seal System.
(1) The two-bottle system consists of the same water-seal bottle plus a fluid collection bottle.
(2) Pleural fluid accumulates in the collection bottle, and not in the water-seal bottle (as in the
single-bottle system).
(3) Drainage depends upon gravity or the amount of suction added to the system.
(4) When suction is added, it is connected at the vent tube in the water-seal bottle.
The Three-Bottle Water-Seal System.
(1) This system consists of the water-seal bottle, the fluid collection bottle, and a third bottle
which controls the amount of suction applied.
(2) The third bottle, called the manometer bottle, has three tubes. One short tube above the water
level comes from the water-seal bottle. A second short tube leads to the suction. The third tube
extends below the water level and opens to the atmosphere outside the bottle. It is this tube that
regulates the suction, depending upon the depth the tube is submerged. It is normally submerged
20 cm (7.6 inches).
(3) The suction pressure causes outside air to be sucked into the system through the tube,
creating a constant pressure. Bubbling in the manometer bottle indicates the system is
functioning properly.
28
Requirements:
Top Shelf
1. Two (2) plane dissecting forceps
2. One (1) inch artery forceps
3. Sterile syringe and needle (5ml)
4. 50ml syringe with aspiration needle size 16. 18. 20.
5. 2 or 3 stop cork with extension tube
6. Sterile dressing towel
7. Sterile glove
Bottom Shelf
1. Mask
2. Receptacle and specimen bottles.
3. Local anesthetic agent e.g. lidocaine (1%)
4. Two trays with B.P. apparatus
5. Adhesive strapping (plaster)
6. A pair of cut scissors
7. Receptacle for used instruments / swabs
Procedure / steps
1. Explain procedure to patient and encourage him to ask questions
2. Send trolley to bedside and provide privacy.
3. Check vital signs and record
4. Put patient in an upright / sitting up position on a chair or bed with head and arm resting
on the bed table / back of the chair.
5. Wash hands, hold anaesthetic agent for the physician to withdraw the require amount.
6. Maintain patient`s position throughout the procedure.
7. Observe patient`s pulse and respiration as well as degree of pain during the procedure
and record
29
8. Encourage patient to remain still and cough during the procedure. If the cough cannot
be suppressed by the patient, the patient can give a signal.
9. Apply a firm dressing at the end of the procedure.
10. Label specimen if any and ensure that they are sent to the laboratory with a signed
request form.
11. Make patient comfortable in bed and remove trolley for decontamination and
sterilization of equipments used.
After care / Observations

Check vital signs hourly especially respiration and record

Report any bloody stains, sputum

Monitor signs of respiratory distress

The patient is placed on the bed and the bottle is placed on the floor and the tubes connected
to the bottle are unclamped.

The tubing is fastened to the bed linen to avoid kinking, looping and pressure on the tube
and to prevent backflow. The tip of the tube should be kept 1.2cm under sterile water

The water level in the bottle is marked by placing one adhesive strip of plaster at the water
line.

Nurses must keep accurate date and hour making sure to write them on the plaster.

It should be noted also that as the patient breaths in and out, there might be movement of
fluid in the glass tube under the bottle.

The tube should be checked for fluctuation frequently and should be milked in the direction
of the drainage bottle every hour to prevent the forrmtion of clot that clamps the tube. If
the column of the water is not fluctuating change the position of patient of ask him to
cough.

Always keep 2 clamps at the bedside. This can be used to clamp the tube whenever needed.
While clamping, clamp the tube close to the chest and for changing the bottle, clamp the
tube in the same way under strict aseptic technique and connect the tube to the new sterile
bottle.

It should be noted also that water seal- drainage should not be shifted/placed above the
patient`s chest level to prevent back flow of fluid
30
Caring for Patient with Under Water-Sealed Drainage
1. Reassures patient and puts patient in the fowlers or semi fowlers position
2. Checks vital signs and records (baseline data)
3. Washes hands and puts on gloves
4. Places the bottle below the chest level in a receptacle
5. Checks the rate and depth of respiration, chest movements and auscultates his lungs
periodically.
6. Observes dressing site for bleeding and dislodgement of tube and inspects air vent in the
system periodically
7. Checks fluid level, fluctuation and bubbling in the drainage system
8. Checks tube for kinking or perforations
9. Encourages patient to cough frequently and breathe deeply every two hours if indicated
10. Assesses patency of drainage system as evidenced by oscillations in the tubing and
bubbling in the water.
11. Tells Patient to report any breathing difficulty immediately.
12. Checks and changes the chest tube dressing when necessary and palpates the area
surrounding the dressing for crepitus.
13. Observes the volume, colour, consistency and odour of the drainage.
14. Thanks, patient, for cooperation
15. Washes hands and administers pain medication as needed for patient`s comfort
16. Washes hands again and documents procedure.
Complications of water seal drainage
-
Haemothorax, usually from laceration of intercostal vessels
Lung laceration if tube is placed too deep
Diaphragm/abdominal cavity penetration
Pain
Tube may fall out
Blocked tubes by a clot
Empyema
Infection
Pneumothorax
POSITIONING OF PATIENTS WITH RESPIRATORY PROBLEMS
31
Patient positioning is an essential aspect of nursing practice. Maintaining good body alignment,
changing positioning regularly and systematically are essential principles of patient positioning
that nurses must consider.
Positioning patients correctly is important for a variety of reasons.
In surgery, proper positioning provides optimal exposure of the surgical site and maintenance of
the patient’s dignity by controlling unnecessary exposure. Additionally, positioning patients
provides airway management and ventilation, maintaining body alignment, and provide
physiologic safety.
COMMON POSITIONS
Fowler’s
•Fowler’s position, is a bed position wherein the head and trunk are raised 40 to 90 degrees.
•Fowler’s position is used for people who have difficulty breathing because in this position,
gravity pulls the diaphragm downward allowing greater chest and lung expansion.
•In low Fowler’s or semi-Fowler’s position, the head and trunk are raised to 15 to 45 degrees; in
high Fowler’s, the head and trunk are raised 90 degrees.
•This position is useful for patients who have cardiac, respiratory, or neurological problems and
is often optimal for patients who have nasogastric tube in place.
BRONCHOSCOPY
The direct inspection and observation of the upper and lower respiratory tract through fiberoptic
(flexible) or rigid bronchoscope as a means of diagnosing and managing inflammatory,
infectious, and malignant diseases of the airway and lungs.
Flexible fiberoptic bronchoscopy allows for more patient comfort and better visualization of
smaller airways, including nasal passages. It is usually performed using local anesthesia with or
without moderate sedation.
Indications
Used for therapeutic and diagnostic procedures such as:
Bronchoalveolar lavage,Endobronchial or transbronchial biopsies,Transbronchial needle
aspiration,Endobronchial ultrasound,Balloon dilation,Endobronchial laser
ablation,ElectrocauteryBrachytherapy,Some types of stent placement.
Rigid bronchoscopy, often performed under general anesthesia with adequate sedation and
muscle relaxants, may be combined with flexible bronchoscopy for better access to distal
airways.
Diagnostic and therapeutic indications include:
Bleeding or hemorrhage, foreign body extractionDeeper biopsy specimen collection than can be
obtained
fiber-optically,Dilation of tracheal or bronchial strictures,Relief of airway obstruction,Insertion
of stents,Tracheobronchial laser therapy or other mechanical tumor ablation.
CONTRAINDICATIONS
uncorrectable coagulopathy, severe refractory hypoxemia, unstable hemodynamic status.
32
Patients with increased risk are those with MI within past6 weeks, head injuries susceptible to
increased intracranial pressures (ICP), and known or suspected pregnancy (due to possible
radiation exposure).
Nursing Care before procedure
1. Check that an informed consent form has been signed and that risks and benefits have been
explained to patient.
2. Make sure that IV access is present and patent.
4.sedate patient depending on hospital protocol
5. Administer prescribed medication to reduce secretions, block the vasovagal reflex and gag
reflex, and relieve anxiety.
6. Restrict fluid and food, as ordered, before procedure to reduce risk of aspiration when reflexes
are blocked. Patient may be kept NPO for 4 hours prior to flexible bronchoscopy with minimal
sedation;if deeper sedation is used, patient’s time on NPO is extended.
7. Remove dentures, contact lenses, and other prostheses.
After the procedure
1. Monitor cardiac rhythm and rate, BP, and level of consciousness
2. Monitor respiratory effort and rate.
3. Monitor oximetry.
4. Withhold ice chips and fluids until patient demonstrates gag reflex.
5. Monitor patient’s perceptions of pain, discomfort, and dyspnea.
6. Promptly report cyanosis, hypoventilation, hypotension,tachycardia or dysrhythmia,
hemoptysis, dyspnea, decreased breath sounds.
7. Provide outpatients with specific instructions regarding signs and symptoms of
complications and what to do if they arise
THORACOSCOPY
Is a diagnostic procedure in which the pleural cavity is examined with an endoscope.
Thoracoscopy is a minimally invasive thoracic surgery performed with the use of small
fiberoptic cameras to look inside the chest through the mouth.
Purpose of Thoracoscopy
a) To visually inspect the lungs, pleura or mediastinum for evidence of abnormalities
b) To obtain tissue biopsies or fluid samples from the lungs, pleura or mediastinum in
order to diagnose infections, cancer, and other diseases.
c) Used therapeutically to remove excess fluid in the pleural cavity or pleural cyst or to
remove a portion of diseased lung tissue (wedge resection).
d) To evaluate patients with pulmonary disease or abnormalities of the sac that surround
the heart or lining of the chest.
e) To obtain a tissue sample for further evaluation and to diagnose inflammation etc.
f) As a minimally-invasive method to perform certain types of surgery, such as
pericardiectomy.
Pre-Operative tests
33
-
Chest x-ray
Electrocardiography
Pulmonary function test
Contraindications
People who have had previous lung surgery, who have severe bleeding disorders or who
cannot breathe with just one lung (since one lung may be partially deflated) or completely
during the procedure
Nursing activities
Pre-operative care
-
-
Explain the procedure to the patient and relatives
Reassure the patient and relatives to allay their anxiety. Show them the instruments if
possible.
Check to see if patient is on any anticoagulant medication or NSAID eg. Aspirin. The
physican may instruct the patient to discontinue certain drugs before the test.
Fast patient for 12 hours before the procedure
Maintain a patent IV line
Ensure the patient bath take care if their oral hygiene.
If any dentures are present, educate the patient to remove them and other prostheses.
Obtain a signed consent form from the patient or significant others
Ensure all tight clothings are removed and patient put in theatre gown.
Check base line vital signs and accompany patient to the theatre with required documents
(folder, x-ray chart)
After the procedure
Continue to monitor patient’s vital signs until he/she recovers from the anaesthesia drug.
Look out for any sign of complications.
Maintain intake and output if drainage tube was insured.
Encourage enough bed rest.
Complications of Thoracoscopy
-
Infection
bleeding
perforation of the diaphragm
Pneumothorax resulting in collapse lungs.
LARYNGOSCOPY
-
Is the visual examination of the voice box, also called the larynx and the vocal cords. It
can be done as a direct or indirect laryngoscopy.
34
-
Indirect laryngoscopy – Uses mirrors to examine the larynx and hypolarynx, which is a
portion of the passageway to the lungs and stomach.
Direct laryngoscopy – Aspecial instrument (a flexible scope) is used.
INDICATIONS
a.
b.
c.
d.
e.
f.
g.
h.
i.
Bad breath that does not go away.
Breathing problems, including noisy breathing (stridor).
Chronic cough
Coughing up blood
Difficulty in swallowing
Feeling that something is stuck in your throat
Long term upper respiratory problem in a smoker
Throat pain that does not go away
Voice problems that lasts more than 3 weeks, including hoarseness, weak voice,
raspy voice, or no voice.
j. A direct laryngoscope may also be used to remove a sample of tissue in the throat for
examinations.
k. To remove an object that is blocking the airway e.g. from a swallowed object.
l. To evaluate a possible cause for persistent earache.
Risks
-
Allergic reaction to anaesthesia agents
Infection
Major bleeding
Nose bleed if scope is passed through the nose
Spasms of the vocal cords, which causes breathing problems
Ulcers in the lining of the mouth
Injury to the tongue or lips.
Pain
Vomiting and gagging.
Contraindications
-
In infants or very young children
If the patient has acute inflammation of the epiglottis
If the patient cannot open the mouth very wide.
Requirements for Laryngoscopy
Laryngoscope with suitable
Diathermy needles.
Local anaesthesia.
Tongue forceps.
35
Specimen bottles with formalin.
Tongue depressor.
Adrenaline 1:1000 solution.
Laryngeal swab holders with swabs
Kidney tray and paper bag.
Dressing towels.
Mark gloves.
Suction catheters and tubing.
Apron for the doctor.
Nursing responsibilities
 Explain the procedure to the patient to allay his anxiety and fear and to win his
confidence and cooperation.
 Approach the patient gently and calmly to prevent unnecessary gagging during
inspection.
 The patient is told to breathe quietly through the mouth.
 Remove any dentures if present
 Food and fluids are withheld for 4-6 hours before examination to prevent possible
aspiration.
 Sedation is given to the patient as prescription.
 Remove dentures.
 If it is done under general anesthesia, a written consent is obtained.
 Maintain strict aseptic technique throughout the procedure.
 After laryngoscopy,under general anaesthesia, the patient is kept flat in bed with head
turned to one side. Fluids are given only after the gag reflex returns.
 Give sips of water to test the swallowing reflex
 Monitor vital signs.
 Observe for swelling of throat and spitting of blood.
 Observe for swelling of throat and neck.
 Observe for restlessness and dyspnea
 Record the procedure in the nurse’s record.
 Educate patient not to try to swallow until their gag reflex returns
 Educate patient to avoid clearing the throat if a sample was taken
Chest physiotherapy
Chest physiotherapy (CPT) includes postural drainage, chest percussion, and vibration, and
breathing retraining.
The goals of CPT are to remove bronchial secretions, improve ventilation, and increase the
efficiency of the respiratory muscles.
POSTURAL DRAINAGE
Postural drainage is the drainage of secretions, by the effect of gravity, from one or more lung
segments, to the central airways. Postural drainage allows the force of gravity to assist in the
removal of bronchial secretions.
36
The secretions drain from the affected bronchioles into the bronchi and trachea and are removed
by coughing or suctioning.
Postural drainage is used to prevent or relieve bronchial obstruction caused by accumulation of
secretions. Because the patient usually sits in an upright position, secretions are likely to
accumulate in the lower parts of the lungs.
Several positions are used so that the force of gravity helps move secretions from the smaller
bronchial airways to the main bronchi and trachea.
Each position contributes to effective drainage of a different lobe of the lungs; lower and middle
lobe bronchi drain more effectively when the head is down, while the upper lobe bronchi drain
more effectively when the head is up. The secretions then are removed by coughing.
Various positions for postural drainage
Dorsal positions,Trendeleburg,Sitting/upright position,Prone position,Lateral left position,Right
lateral position,Side lying semi fowlers etc.
Purpose
1. Loosens secretions in airways.
2. Uses gravity to draw and remove excessive secretions.
3. Decreases accumulation of secretions in unconscious or weak patients.
Indications.
1. Chronic obstructive pulmonary disease
2. Bronchial Asthma.
3. Lung Abscess.
4. Atelectasis
5. Bronchiectasis
6. Following chest injuries and chest surgeries.
7. Cystic fibrosis
8. Presence of artificial airway with retained secretion.
Contraindications
Hypertension
Extreme dyspnoea
Severe respiratory distress
Increase Intracranial pressure
Head and neck injuries ,Spinal injury, Empyema(pus in the pleural cavity),Pulmonary edema
associated with congestive heart failure ,Bruises on skin,Pulmonary embolism,Aged, confused or
anxious patients who do not tolerate change in position,Rib fracture
REQUIREMENT FOR POSTURAL DRAINAGE
1. Hospital bed that can be placed in Trendelenburg position.
2. Chair for draining upper lobes.
3. Pillows
4. Facial tissues, paper bag.
5. Drinking water.
6. Disposable gloves, gown, mask.
7, Towel for covering area of chest during percussion.
37
8. Suction machine for client in enabling to clear secretion.
Procedure (Before and During)
1. Explain and demonstrate procedure to client and family to relax and cooperate.
2. Wash hands and organize equipment.
3. Administer bronchodilators, expectorants or warm liquids, if ordered or desired.
4. Encourage client to void or empty bowel and bladder.
5. Position client to drain specific lung area.
To drain upper lung segments/lobes, position client;
- Sitting upright in bed or chair, perform therapy to right and left chest – Drains anterior right
and left apical segments.
- Leaning forward in sitting position, perform therapy to back - Drain posterior right and left
apical segments.
- Lying flat on back, perform therapy to right and left chest - Drain anterior segments.
- Lying on abdomen, tilted to right or left side, perform therapy to right or left back - Drain
posterior segments.
- To drain middle lobe, position client:
- Lying on back, tilted to left side in Trendelenburg’s position, therapy to right chest - middle
interior lobe).
- Lying on abdomen, tilted to left side, with hips elevated, therapy to right back - middle
posterior lobe.
Lying in Trendelenburg’s position on back, perform therapy to right and left chest — anterior
basal lobes.
- Lying in Trendelenburg’s position on abdomen, perform therapy to right left back — posterior
basal lobes.
- On right or left side in Trendelenburg’s position, perform therapy to back drains lateral basal
lobes.
6. Maintain client in position until chest percussion and vibration are completed.
7. Assist client into position for coughing, or position client for suctioning of trachea
8. Position client to drain next target area and repeat percussion and vibration.
9. Continue sequence until identified target areas have been drained.
Nurse‘s Responsibilities
- Put the patient in a comfortable position.
- Tissue paper must be provided to patient to spit out secretions in the mouth and clean in
course of procedure.
- The patient should be instructed to remain quite in each position put.
- Encourage him to breathe slowly through his nose and blow through the mouth.
- Instruct him to cough between each position.
- The patient is instructed to stay in the bed for half-an-hour after the postural drainage so
that he may get rest.
- Mouth care should be given after the procedure.
- Have client take sips of water.
- Have client take enough rest after procedure.
- Report any findings where necessary.
NURSING MANAGEMENT
-
Explain the procedure to the patient and allow them to express their fears.
38
-
-
Reassure them to alley their anxiety.
Remove any tight clothing around the chest.
Check the baseline vital signs.
Educate the patient on the need for the procedure and explain any possible side effect or
complication.
The Nurse should be aware of the patient’s diagnosis as well as the lung lobes or
segments involved. This will help the nurse know the position to put the patient in.
Postural drainage is usually performed 2 or 4 times daily before meals (to prevent nausea,
vomiting and aspiration) and at bedtime.
Prescribed bronchodilators, water, or saline may be nebulised and inhaled before the
procedure to dilate the bronchioles, reduce bronchospasm, decrease the thickness of
mucus and sputum, and combat oedema of the bronchial walls.
The recommended sequence starts with positions to drain the lower lobes, followed by
position to drain the upper lobes.
The Nurse makes the patient comfortable in position (Sitting, lying on the back, stomach,
or side, Sitting or lying with the head flat, up, or down)
Instruct the patient to remain in each position for 10 – 15 minutes and to breathe in
slowly through the nose and out slowly through pursed lips to help keep the air way open.
If a position cannot be tolerated, help the patient into a modified and teach patient to
cough.
If the patient cannot cough, the nurse may need to suction the secretions mechanically.
After the procedure, the nurse must note the amount, colour, viscosity, and character of
the expelled sputum.
Evaluate the patient’s skin colour and pulse the first few minutes the procedure is
performed.
Oxygen may also be administered during the procedure.
Perform procedure away from other patients or relatives if the secretion is foul –
smelling.
Deodorizers may be used to counter act the odour. Because aerosol sprays can cause
bronchospasm and irritation, they should be used with caution.
Perform mouth care for the patient after the procedure or allow patient to brush the teeth.
REQUIREMENTS
-
A suctioning apparatus
Vomit / emesis bowl
Sputum mug / cup
A paper tissue / gauze
Gloves
Extra pillows
Bed elevator / back rest
39
-
Drainage bag
Chest Percussion and Vibration
Thick secretions that are difficult to cough up may be loosened by tapping (percussing) and
vibrating the chest.
Chest percussion and vibration help dislodge mucus adhering to the bronchioles and bronchi.
Percussion is carried out by cupping the hands and lightly striking the chest wall in a rhythmic
way over the lung segment to be drained.
The wrists are alternately flexed and extended so that the chest is cupped or clapped in a painless
manner. A soft cloth or towel may be placed over the segment of the chest that is being cupped
toprevent skin irritation and redness from direct contact. Percussion, alternating with vibration, is
performed for 3 to 5 minutes for each position.
As a precaution, percussion over chest drainage tubes, the sternum, spine, liver, kidneys, spleen,
or breasts (in women) is avoided.
Percussion is performed cautiously in the elderly because of their increased incidence of
osteoporosis and risk of rib fracture.
Vibration is the technique of applying manual compression and tremor to the chest wall during
the exhalation phase of respiration.This helps increase the velocity of the air expired from the
small airways, thus freeing the mucus. After three or four vibrations, the patient is encouraged to
cough.
Complications of postural drainage & management
1. Hypoxemia patient becomes hypoxemic during the procedure, administer 100% Oxygen,
stop the therapy immediately, return patient to original resting position and inform the
physician. Ensure adequate ventilation. Hypoxemia during postural drainage may be avoided
in unilateral lung disease by placing the involved lung uppermost with patient on his/her side.
2. Increased intracranial pressure. When this occurs stop the procedure and consult the
physician.
3. Acute Hypotension.
4. Pulmonary haemorrhage. Administer Oxygen and maintain an airway until the physician
responds.
5. Pain or injury to the ribs. Take care in turning the patient and consult the physician.
6. Vomiting and aspiration.
Stop the procedure, clear the airway and suction as needed, administer oxygen, maintain
airway and return the patient to the original position.
7. Bronchospasm
8. Dysrhythmias.
TRACHEOSTOMY
-
Tracheostomy is a surgically created hole through the front of the neck in to the wind
pope (trachea) the term for the surgical procedure to create the opening is tracheotomy.
40
-
-
A tracheostomy provides an air passage to the help you breathe when the natural / usual
route for breathing is somehow obstructed or impaired.
A tracheostomy is often needed when health problems require long – term use of a
ventilator to help the patient breath. In rare cases an emergency tracheostomy is
performed when the airway is suddenly blocked, such as after a traumatic injury to the
face or neck.
It can be permanent or temporal in some patients
A tube is inserted through a cut in the neck below the vocal cords. This allows air to enter the
lungs.
Breathing is then done through the tube, bypassing the mouth, nose and throat. The hole in which
the passes in tracheostomy is called a stoma. This hole is created between the second and third
tracheal rings.
Uses of Tracheostomy
 To facilitate prolong artificial ventilation.
 To serve as a bypass to remove upper respiratory obstructions.
 To make an easy access to have respiratory tract than making it in the nose and mouth.
 To prevent aspiration of blood, secretions or food into the lungs
There are three main parts of the tube
1. Outer tube/cannula — inserted into the trachea and a flange that rests against the neck and
allows the tube to be secured in place with ties.
2. Inner tube/cannula — removed periodically for cleaning.
3. Obturator/pilot — used to insert the outer cannula and then removed and used again in case
of dislodge of tube and needs to be inserted.
INDICATION
1. Acute respiratory failure, central nervous system (CNS) depression, neuromuscular disease,
pulmonary disease, chest wall injury.
2. Upper airway obstruction (tumor, inflammation, foreign body, laryngeal spasm).
3. Anticipated upper airway obstruction from edema or soft tissue swelling due to head and
neck trauma, some postoperative head and neck procedures involving the airway, facial or
airway burns, decreased LOC.
4. Need for airway protection (vomiting, bleeding, or altered mental status).
5. Aspiration prophylaxis.
6. Fracture of cervical vertebrae with spinal cord injury; requiring ventilatory assistance.
General Nursing Management
1. Psychologically recognize that patient is usually apprehensive, particularly about
choking, inability to communicate verbally, inability to remove secretions, uncomfortable
suctioning, difficulty in breathing, or mechanical failure.
2. Inform patient and family that speaking will not be possible while the tube is in place,
unless using a tracheostomy tube with a deflated cuff, a fenestrated tube, a speaking valve
(that fits over the end of the tracheostomy tube. Air that is inhaled is exhaled through the
41
vocal cords and out through the mouth, allowing speech), or a speaking tracheostomy
tube.
3. To communicate, patient can use sign language, lip movement, letter boards, paper and
pencil, magic slate, or coded messagesFor patient to get the nurse’s attention when
someone is not immediately available at the bedside,such as call bell, hand-operated bell,
or rattle.
4. Ensure adequate ventilation and oxygenation through the use of supplemental oxygen or
mechanical ventilation as indicated.
5. Assess breath sounds every 2 hours. Note evidence of ineffective secretion clearance
(rhonchi, crackles), which suggests need for suctioning.
6. Provide adequate humidity when the natural humidifying pathway of the oropharynx is
bypassed.
7. Provide adequate suctioning of oral secretions to prevent aspiration and decrease oral
microbial colonization
8. Perform frequent oral care with soft toothbrush or swabs and antiseptic mouthwash or
hydrogen peroxide diluted with water. Frequent oral care will aid in prevention of ventilator
associated pneumonia. The patient’s lips should be kept moisturized with petroleum jelly to
prevent them from becoming sore and cracked.
9. Elevate the patient to a semi-Fowler’s or sitting position, when possible; these positions
result in improved lung compliance.
10. The patient’s position, however, should be changed at least every 2 hours to ensure
ventilation of all lung segments and prevent secretion stagnation and atelectasis. Position
changes are also necessary to avoid skin breakdown.
11. Administer oral feedings to a conscious patient with a tracheostomy, usually with the cuff
inflated. The inflated cuff prevents aspiration of food contents into the lungs, but causes the
tracheal wall to bulge into the esophageal lumen, and may make swallowing more difficult
12. Perform tracheostomy site care at least every 8 hours using hydrogen peroxide and water,
and change tracheostomy ties at least once per day
13. Monitor vital signs,especially respiration every 15-30 mins for the first 24-48hrs and observe
closely for signs of respiratory distress e.g. noisy and labored respiration restlessness
cyanosis etc.
14. Observe for complications of tracheostomy. Examples of complications include obstructive
sign, haemorrhage, atelectasis, pneumothorax, emphysema. If the airway is obstructed,
suction and clean the tube. And if the outer tube is coming off, put a trachea dilator inside the
tube and immediately inform the doctor
15. Proper care of the wound should be ensured by maintaining aseptic technique when changing
dressing. The area around the stoma must be always kept dry and clean
16. Use sterile technique when suctioning and performing tracheostomy care.
17. . Keep necessary articles like an extra sterile inner cannula, trachea dilator, Vaseline sterile
gauze, distilled water and the suction apparatus by the patient.
42
18. Keep materials or articles which may occlude the tracheostomy away from the opening. E.g.
Bed sheet.
NB: In case of tracheostomy tube removal,use a bag/mask resuscitation
device to ventilate the patient by mouth while covering tracheostomy stoma. However, if the
patient has complete upper airway obstruction, a gaping stoma, mouth-to-stoma ventilation must
be performed.
Care of Patient with Tracheostomy Tube
Rationale for caring tube
- To ensure tube remains patent
- To reduce the risk of respiratory infection
- Initially the tube may need to be suctioned and cleaned every 1-2hrs.After 48hrs however
it may be done once or twice daily.
Equipment
Sterile and disposable gloves
Hydrogen peroxide
Normal saline solution or sterile water
Sterile suction catheter
Towel or drape to protect patients clothing
Sterile Dressing pack
Sterile scissors
Sterile brush
Receptacle for soiled items
Procedure
Explain to the patient what you are going to do and gain consent
Provide privacy
Prepare and send trolley to the patient’s bedside
Put patient in semi fowlers or fowler’s position to promote lung expansion
Drape patient with towel
Teach patient how to communicate with you to indicate pain or discomfort e.g. raising finger
or keeping paper within the patient’s reach at all times
7. Wash and dry hands
8. Wear disposable gloves and suction the tracheostomy tube to remove secretions and ensure a
patent airway
9. Remove the inner tube by turning the lock about 90 degrees anticlockwise and pull it out
gently
10. Soak the inner cannula in hydrogen peroxide solution for several minutes to moisten and
loosen ant dried secretion
11. Suction the outer cannula
12. Remove the disposable gloves wash and dry hands and put on sterile gloves
13. Remove the inner tube from the hydrogen peroxide solution into a sterile bowl containing
normal saline solution
14. Clean the lumen and entire inner tube thoroughly with the brush
15. Rinse the inner tube in a clean saline solution and dry the inner side of the tube with gauze
swabs
1.
2.
3.
4.
5.
6.
43
N.B Don’t dry the outer side. Drying the inner side of the tube prevents possible aspiration while
leaving a film of moisture on the outer side lubricates the cannula for re insertion
16. Re insert the inner cannula into the outer cannula and secure it in place
17. Clean the stoma and the tube flange with gauzeswabs soaked in saline solution. If there are
no debris or crust clean with hydrogen peroxide before the saline solution.
18. Apply sterile dressing under the flange of the tube ensuring that the tube is securely
supported
19. Change the ties tapes if necessary to keep the skin clean and dry
20. Thank patient
21. Discard the trolley and decontaminate used items
22. Wash rinse dry items
23. Remove gloves,wash and dry hands
24. Document procedure
25. Call physician if patient experiences
- Fever or chills
- Bleeding from stoma
- Redness, swelling or pain that is deteriorating
- Cough or shortness in breath even after suctioning
- Nausea or vomiting
N.B If the tracheostomy tube accidentally falls out, do not push it back. Cover the site with a
piece of sterile gauze soaked in normal saline and inform physician
Performing Tracheal Suctioning Requirements
-
Suction catheters
Gloves (sterile andnonsterile)
Mask, gown, goggles
Basin for sterile normal saline solution for irrigation
Manual resuscitation bag with supplemental oxygen
Suction machine.
Procedure
1. Assess the patient’s lung sound and oxygen saturation level. This enables the nurse to
monitor the effect of suction on the patient’s oxygenation levels
2. Explain the procedure to the patient and reassure him before and during the procedure to
allay their fears and anxiety
3. Wash hands and wear disposable gloves, goggles, mask and gown
4. Turn on suction source (pressure should not exceed 120mmHg) to prevent causing
trauma to the tissues.
5. Open suction catheter kit to prevent interruption of the procedure.
6. Fill basin with sterile water
7. Wear sterile gloves
44
8. Ventilate patient with manual resuscitation bag and light-flow oxygen for about 30
seconds to prevent hypoxia during the procedure
9. Instill normal saline into the airway if there are thick, tenacious secretions
10. Connect suction catheter to suction machine
11. Insert the catheter as far as the end of the tube without applying suction, just far enough
to stimulate the cough reflex
12. Apply suction while withdrawing and gently rotating the catheter 360⁰ (no longer than 10
– 15 seconds) prolonged suctioning may result in hypoxia and dysrhythmias, leading to
cardiac arrest.
13. Rinse catheter by suction few militates of saline between suction attempts.
14. Repeat step 9–13 until the airway is clear
15. Suction the or pharyngeal cavity after tracheal suctioning to avoid contaminating the
tracheal tube
16. Rinse suction tubing and discard the catheter gloves and other disposables.
17. Decontaminate equipment and clean
18. Assess the patient lung sound and oxygen saturation after the procedure.
19. Document the amount color, consistency of secretions
Complications
1. Laryngeal or tracheal injury (Sore throat, hoarse voice,Glottic edema.Trauma (damage to
mucous membranes, perforation or laceration of pharynx, larynx, or trachea),Aspiration,
Laryngospasm, bronchospasm,Ulceration or necrosis of tracheal mucosa, Vocal cord ulceration,
granuloma, or polyps,Vocal cord paralysis,tracheal stenosis,Tracheal dilation,tracheal–
esophageal fistula,tracheal–arterial fistula)
2. Pulmonary infection and sepsis.
3. Dependence on artificial airway.
SUCTIONING
Suctioning is a procedure that removes excess secretions from the mouth and throat
(oropharynx), from the nose and throat (nasopharynx), and from the windpipe (trachea) using a
mechanical aspiration device (Suction machine).
PURPOSE
To stimulate the cough reflex in patients who are unable to clear secretions by coughing
To maintain patent airway
To promote optimal exchange of oxygen and carbon dioxide
Indications
45
Unconscious patients
Patients who have been intubated
Patients with tracheostomy
Requirements
Sterile gloves
Suction machine
Sterile suction catheter
Oxygen source or ambu bag
Tracheostomy care tray if necessary
Sterile gallipot
Normal saline solution or sterile water
Mackintosh cape and towel
Procedure
1. Explain procedure to patient and provide privacy
2. Send prepared trolley to bedside
3. Assess the patients’ respiratory rate,rhythm,depth,breath sounds,oxygen saturation level
etc. to establish baseline comparison
4. Put patient in semi fowlers or fowlers position, unless contraindicated to promote lung
expansion.in unconscious patient turn patient to their side to prevent the tongue from
falling back
5. Wash and dry hands and put on sterile gloves
6. Instruct assistant to pour normal saline solution or sterile water into the gallipot.
7. Drape patient with mackintosh cape and towel
8. Open the suction catheter kit and remove it from its wrapper
9. Keep it coil so that it doesn’t touch anything
10. Use your non dominant hand to attach the connecting tubing on the suction machine to
the suction catheter
11. Switch on the suction machine
12. Dip the tip of the suction catheter into the saline solution to lubricate it
13. With the tip of the catheter in the saline solution occlude the control valve with the thumb
of the non dominant hand. Suction a small amount of the solution through the catheter to
lubricate it and facilitate the passage of secretions through it
14. In naso tracheal suctioning use the non dominant hand to raise the tip of the patient nose
to straighten the passage and facilitate the insertion of the catheter
15. Do not apply suction during the insertion to avoid tissue trauma and oxygen loss
In an intubated patient gently insert the suction catheter into the artificial airway
16. Advance the catheter without suctioning until resistance is met
46
17. After inserting the catheter apply suction intermittently by removing and replacing the
thumb of the non dominant hand over the control valve.Simultaneously use your
dominant hand to withdraw the catheter as you roll it between your thumb and forefinger
18. Never suction more than 10 seconds at a time
19. If the patient is intubated, use the non dominant hand to stabilize the tip of the
endotracheal tube as you suction to prevent accidental extubation
20. Observe patient and allow patient to rest for few minutes before suctioning again
21. If secretions coming out are thick, clear the catheter periodically by dipping the tip in
saline solution to and apply suction
22. If necessary continue with oxygen administration after the procedure
23. Clear the suction catheter and connecting tubing by aspirating the remaining saline
solution through it
24. Replace suction equipment and discard supplies according to the hospitals protocol
25. Wash and dry hands
26. Auscultate the lungs bilaterally and check vital signs to access the effectiveness of the
procedure
27. After suctioning, flush the catheter with distilled water to rinse away mucus, followed by
suctioning of air through the device to dry the internal surface to discourage microbial
growth. The outer surface of the device may be wiped with alcohol or hydrogen peroxide.
28. The suction catheter should be allowed to air dry and then stored in a clean, dry area for
reuse.
Observations during suctioning
o Observe the skin color. (Including the presence or absences of cyanosis
o Monitoring pulse rate before and after suction.
o Check blood pressure and Oximetry if you have the equipment.
o Observe the color and odour of the sputum and informed physician
POSITIONING OF PATIENT WITH RESPIRATORY PROBLEMS
The patient sits up in bed supported with pillows at 90 degrees or 45 degrees. This can be used in
nebulising asthmatic patients. Thoracentesis and chest radiology is taken upright if patient’s
condition permits. This position improves breathing capacity, prevents aspiration and
complications in post chest operations as well as ensures that the diaphragm is most dependent and
facilitates the removal of fluids that is usually localized at the base of the chest.
Positioning the Breathless Patient
Patient preparation includes explaining the procedure to gain consent and co-operation as patient
may be anxious because of the difficulty in breathing.
Equipment
47
1. Bed with adjustable backrest or electric raising mechanism
2. Four or five pillows, Bed table with brakes, Firm, supporting armchair
3. A hoist or sliding aid may be needed if the patient is unable to move up the bed unaided.
Procedure
1. Explain to the patient exactly what is planned so that movement is reduced to a minimum
2. Ask/assist the patient to sit forward. A second nurse may be needed to support the patient
while the backrest is adjusted and the pillows are arranged.
3. Adjust the backrest or raise the head of the bed
4. Arrange the pillows so that the patient feels supported. This will vary according to the
patient preference but you should ensure that the lumber region is supported
5. If the foot of the bed can be raised slightly this may help to prevent the patient slipping
down
6. For a short period, the patient may get relief by leaning forward with the forearms resting
on a pillow on a bed table (heart table)
7. If able to get out of bed, the breathless patient is often must comfortable sitting in an air
chair, and many prefer to sleep in this position
8. Document care given and report any changes in condition
CHAPTER THREE
NURSING CARE OF PATIENTS WITH GASTROINTESTINAL DISORDERS
BARIUM MEAL
A barium meal is a procedure used to see what is going on in the oesophagus, stomach and
duodenum.
-
The patient is given a barium solution to swallow. After it has sufficiently coated
everything in the GIT, an x-ray is taken. It is more intensive than barium swallow is used
to see the upper digestive tact.Barium meal spot lights growths, lumps, abnormalities etc
BARIUM SWALLOW (UPPER GASTROINTESTINAL SERIES)
Upper GI series is fluoroscopic x-ray examinations of the esophagus, stomach, and small
intestine after the patient ingests barium sulfate. As the barium passes through the GI tract,
fluoroscopy outlines the GI mucosa and organs.
Indications
48
1. Oesophagus varices
2. Tumours of the upper G.I.T.
3. Strictures
4. Hiatal hernia
5. Patient with peptic ulcers
Procedure
Before
1. Explain procedure to patient.
2. Tell patient to fast 4-6 hours before the test.
3. Instruct patient to maintain low-residue diet for 2 to 3 days before test and a clear liquid
dinner the night before the procedure.
4. Emphasize NPO after midnight before the test.
5. Encourage patient to avoid smoking before the test.
6. Explain that the health care provider may prescribe all opioids and anticholinergics to be
withheld 24 hours before the test because they interfere with small-intestine motility.
Other medications may be taken with sips of water, if ordered.
7. Explain that the patient will be instructed at various times throughout the procedure to
drink the barium (480 to 600 mL)
8. Make sure patient has adequately prepared by giving a laxative 24 hours before the
procedure.
9. The nurse explains to the patient that he would be given a drink flavoured chalky
substance (barium) in the radiologic department after which x-ray will be taken.
10. In cases of suspected pyloric stenosis aspirate the stomach 30 minutes before the
examination.
After
1. Administer laxative to eliminate the barium after the procedure.
2. Observe the regularity of bowel elimination and the passage of barium.
3. Tell patient to take in a lot of fluid or water to help eliminate barium.
4. notify physician if patient has not passed the barium in 2 to 3 days because retention of the
barium may cause obstruction or fecal impaction
Complications
- There may be faecal impaction due to retained barium.
- Hypokalaemia caused by aggressive bowel cleansing
- Dehydration in some patients especially the elderly
- Constipation from hardening of remained barium
- Inflammation in the colon caused by small clumps of retained barium termed barium
granulomas.
- Perforation of the colon (rare) leading to chemical peritonitis.
- Narrow or blocked colon.
- Because of these side effects, individuals with weakened bowel walls as in ulcerative
colitis or crohns’ disease are not good candidate for this procedure
BARIUM ENEMA (LOWER GASTROINTESTINAL SERIES)
What is an Enema?
49
Is the introduction of solution into the rectum and large intestines for the purpose of cleansing,
giving medication or for investigation purposes.
Enema is grouped into 3 namely:
1. Cleansing/evacuant enema; they are given to clear the rectum or move faeces by the use
of Naso4, Maso4, plain water, normal saline etc.
2. Carminate enema; they are given preliminary to expel flatus.
3. Retention enema; they are given to introduce drugs for absorption or radio-opaque
substances for x-ray.
NB: Barium enema is a type of retention enema with the use of barium sulphate prior to
x-ray.
Barium enema, also called lower gastrointestinal series is a medical procedure used to examine and
diagnose problems with the lower GIT (colon/large intestines). X-ray pictures are taken after barium
sulphate is introduced into the large intestines through the anus. It serves as a contrast medium to
visualize clearly x-ray images of the large intestines to detect any abnormalities. A tube is inserted in to
the rectum and a barium solution is passed in to the lower bowels (colon). The barium coats the colon,
enabling a clear view of anything that is wrong with that area of the bodyIn this procedure the patient is
given barium and x-ray of the large intestines are taken.
Indications
1. In cases of a colon obstruction.
2.In cases of volvulus
3. Occult in blood in the stool.
4. Appendicitis.
5. Inflammatory bowel diseases.
6.Intussusceptions
7.In cases of suspected bowel cancer
8.In cases of hernia.
9.Fistula involving the colon.
10.In crohn’s disease
11.Colonic stenosis
12.Diverticulitis
Preparation before procedure
1. Explain procedure.
2. tell patient that it is important to retain the barium so all surfaces of the tract are coated with
opaque solution. So, Tubes with balloon may be used to help the patient to retain the barium.
3. Patient may be given a low-fiber, low-fat diet 1 to 3 days before the examination.
4. The day before examination, intake may be limited to clear liquids (no drinks with red dye).
5. The day before the examination, an oral laxative, suppository, and/or cleansing enema may be
prescribed.
6. Patient will be NPO after midnight the day of the procedure.
7. On the morning of the test, patient is given enema until returns are clear and the bowel is free
of fecal matter.
50
8. Nurse explains to patient that the barium enema will create a feeling of fullness and the patient
may feel the edge to defecate and slight abdominal cramp.
9. Tell patient that he will assume various positions during the procedure so must cooperate.
10.Tell patient that this procedure is not going to last for an hour.
After
1. Provide patient with enough rest since procedure is very tiring.
2. Resume the patient regular diet starting with light snacks.
3. Observe the regularity of the bowel elimination and the passage of barium.
4. Tell patient to take in a lot of fluids and fluid diet.
5. An enema or cathartic may be ordered after the barium enema to cleanse bowel of barium and
prevent impaction.
6. Inform patient that barium may cause light-colored stools for several days after the procedure
7. Suggest the use of a soothing ointment at the anal area or region to minimize anorectal pain.
Complications of barium enema
-
Severe constipation due to hardened barium solution. This can be prevented by taking
copious fluids or mild laxatives after the test.
Barium granulomas (rare)
Perforation of the bowel. Pressure from air or barium causes a weakened portion of the
bowl to break up.
FRACTIONAL TEST MEAL
Fractional test meal is done to find out the amount of hydrochloric acid in the stomach. The test
is done by first taking a fasting specimen and the post stimulation specimen. The fasting volume
of resting stomach juices is about 20mls to 50mls, if it is less, is an indication of pernicious
anaemia. If it more than 250mls it may suggest the presence of pyloric sternosis or gastric
carcinoma. The normal colour is slightly brownish, if there is blood stain that may be an
indication of a gastric carcinoma. When there is presence of blood, it indicates that there is ulcer,
carcinoma, trauma, esophageal varice, bleeding gum pyloric stenosis. Some medicine could also
change the colour example iron tablets. When it is normal it is odourless and normally it is
acidic. For normal content there are traces of mucous but if excessive the mucous is excessive
then it may indicate gastritis. If bile is present in all the specimens collected then it is due to an
abnormal functioning of the pylorus
Indications
-To diagnose peptic ulcer
-Gastric carcinoma
-Pyloric stenosis
-Suspected pernicious anemia
PREPARATION
-Explain procedure to patient.
-Reassure patient.
-Educate patient to fast for at least 12hrs.
Requirements
A tray for passing NG tube.
Measuring jug
51
Litmus paper
Two gallipot with one containing swabs
Receiver
Vomit bowl
Mouthwash
Syringe and needle
Alcohol
Cup containing gruel (feed)
Histamine 0.5mg in syringe if ordered
Procedure
1. The test is carried out early in the morning.
2. Keep patient on nil per OS i.e. should not take anything before the test at least 12 hours
before last meal should be supper the night before the test.
3. Explain procedure to patient to win his cooperation
4. On the morning of the test pass N.G tube and aspirate gastric content with 20cc syringe.
5. The gastric content is collected into a bottle and labeled as a resting juice.
6. Give patient a test meal to drink and note the time it was given. Test meal should be
50mIs of 7% alcohol.
7. Aspirate 5mIs of gastric juice at15-20 minutes interval into separate test tubes.
8. Label each test tube with the time the juice was taken
9. Test the 1st and 2nd withdrawn gastric juice with the litmus paper for acidity
10. Remove tapes,pinch the tube and gently but briskly withdraw it
11. Give the patient a mouthwash and make him comfortable in bed
12. Ensure specimen is well labeled and send to the laboratory with the request form well
filled.
13. Discard trolley decontaminate and wash used items.
14. Closely monitor patient for signs and symptoms of pneumothorax.eg shortness of breath,
chest pain, rapid heart rate, etc.
NB. If gastric content is blood stained then there is an indication of cancer or peptic ulcer or an
oesophagus varice.
If there is presence of bile in the specimen it is an indication of abnormal function of the pylorus.
If there is excess mucous there is an indication of gastritis.
PARACENTESIS ABDOMINIS(ABDOMINAL PARACENTESIS,PERITONEAL TAP,
ABDOMINOCENTESIS,PERITOCENTESIS)
It is the insertion of a trocar through a small incision and into the peritoneal cavity with the aim of
removing ascetic fluid or inject a therapeutic agent.
TYPES OF PARACENTESIS ABDOMINIS
Diagnostic paracentesis: is the removal of a small quantity of fluid for testing
Therapeutic:is the removal of 5 liters or more of fluid to reduce intra-abdominal pressure and
dyspnea
52
Peritoneovenous shunt:a permanent procedure and is for relief of accumulation of excess fluid
in the peritoneal cavity
Purposes of Abdominal Paracentesis
1. To relieve pressure symptoms associated with Ascites. To relieve pressure on the abdominal
and chest cavity when a transudates collects as a result of renal, cardiac or liver diseases.
2. To make diagnosis - obtain specimen to study chemical, bacteriological and cellular
composition of the peritoneal fluid for the diagnosis of diseases.
3. To drain — an exudates is drained in peritonitis
4. To give treatment — to administer substances such as radioactive and cytotoxic drugs (e.g.
cisplastin, bleomycin) or other agents into the peritoneal cavity to achieve regression of serosae
deposits responsible for fluid formation.
Sites for Abdominal Paracentesis
The site is mainly selected to avoid injury to the urinary bladder and other organs.
A common site is the midway between the symphysis pubis and the umbilicus on the midline
A point, two thirds, along a line from the umbilicus to the anterior superior iliac spine
Indications
1. Cirrhosis of liver
2. Advanced congestive heart failure
3. Chronic pericarditis: Where tumour seeds into the peritoneum.
4. Malignant conditions such as metastatic cancer of the ovary, stomach, colon or
peritoneal carcinomatosis
Contraindications
- Patients with coagulation abnormalities or bleeding tendencies.
- Patients with only a small amount of fluid
- Extensive previous abdominal surgery.
- Pregnancy
- Abdominal wall cellulitis
- Distended bowel
- Intra-abdominal adhesions.
Procedure
Requirements
Sterile abdominal paracentesis set containing forceps, scalpel blade and blade holder, swabs,
towels, suturing equipment, trocar and cannula (or other approved catheter and introducer)
rubber tubing to attach to the cannula and large sterile drainage bag or container
Sterile dressing pack
Sterile receiver
Sterile specimen bottle
Local anaesthesia agent e.g. lidocaine
Needles and syringes
Antiseptic cleansing lotion of methylated spirit
Adhesive plaster/strapping
Clamps
Sterile gloves
Weighing scale if appropriate
Tape measure if appropriate
53
Mackintosh and towel
A resuscitation tray
Before procedure
- Explain procedure to the patient. Make sure that consent form has been signed.
- Verify that a consent form has been signed
- Ask for patients’ allergies
- Make sure they not on anti-coagulant, pregnant, or likely to be pregnant
- Check and record the patient’s vital signs.
- Measure patient’s abdominal girth and weight.
- Encourage patent to void or pass a catheter if necessary to avoid accidental puncturing of
the bladder
- Position patient in Fowler’s position with back, arms, and feet supported
- Drape patient with sheet exposing abdomen
During procedure
-
Assist in preparing skin with antiseptic solution.
Open sterile tray and package of sterile gloves; provide anesthetic solution.
Have collection bottle and tubing available.
Assess pulse and respiratory status frequently during procedure; watch for pallor,
cyanosis, or syncope (faintness).
- Physician gives local anesthesia and introduces needle or trocar.
- Needle or trocar is connected to tubing and vacuum bottle or syringe; fluid is slowly
drained from peritoneal cavity.
- Apply dressing when needle is withdrawn
if the wound is large, the physician may close the incision with sutures and wound dressed
After procedure
1. Assist patient to a comfortable position after treatment.
2. Record amount and characteristics of fluid removed, number of specimens sent to laboratory,
and patient’s condition during treatment.
3. Measure patient’s abdominal girth and weight
4. Check vital signs especially blood pressure every hour for 2 hours, every hour for 4 hours, and
every 4 hours for 24 hours.
5. Monitor for leakage or scrotal edema after paracentesis
LIVER BIOPSY
Sampling of liver tissue through needle aspiration to establish a diagnosis of liver disease
through histologic review.
INDICATIONS
-Chronic liver disease
-Liver tumours
-Alcoholic liver disease
--Hepatits
-Haemochromatosis (too much iron in the blood)
CONTRAINDICATIONS
-Significant coagulopathy
-Significant thrombocytopenia
54
-Significant ascites
-Pregnancy
Before procedure
1. Explain the procedure to the patient including the complications & importance.
2. Establish baseline hemoglobin level, hematocrit, and platelet count.
3. Check if the patient is on any blood thinning drug e.g. Coumadin and inform the Doctor
4. Check baseline vital signs
5. Check for signed consent form
6. Give preprocedural medications as ordered. Vitamin K may be given for several days
before the biopsy to reduce the risk of hemorrhage.
7. Ensure that the client fasts for at least 2 hours before the procedure.
8. Help the client assume a supine position with the upper right quadrant of the abdomen
9. Inform the patient that cooperation in holding their breath for about 10 seconds during the
procedure is important to obtain biopsy without damaging the diaphragm.
10. An IV may be inserted for sedation, as needed.
After procedure
1. Position patient on right side with pillow supporting lower rib cage for several hours.
2. Check vital signs and observe biopsy site frequently for bleeding or drainage.
3. Report increasing pulse, decreasing blood pressure (BP),increasing pain, and apprehension,
which may indicate bleeding
Complications of liver biopsy
-
Infection
Bleeding
Peritonitis
Pneumothorax (lung collapse)
Injury to the intestine, gallbladder or kidneys.
ENDOSCOPIES
TYPES OF ENDOSCOPIES AND AREAS OF VISUALIZATION.
TYPES
Arthroscopy
Bronchoscopy
Colonoscopy
Colposcopy
Cystoscopy
Enteroscopy
Esophagogastroduodenoscopy
Gastroscopy
Hysteroscopy
Proctoscopy/anoscopy
Fundoscopy/ophthalmoscopy
Laparoscopy
Otoscopy
AREA OF VISUALIZATION
joint
Larynx, trachea, brochus and alveoli
Rectum and colon
Vagina and cervix
Urethra, bladder, urether and prostate
Upper colon and small intestines
Esophagus, stomach, duodenum
Stomach
Uterus
Visualize rectum and anal canal
Fundus of eye
Abdominal cavity
Ear
55
Sigmoidoscopy
Thoracoscopy
Laryngoscopy
Anus, rectum, sigmoid colon
Pleural and lung
larynx
ENDOSCOPY
It is a direct visualization of internal body organs and cavities by using an endoscope.
Endoscopes are tubular instruments with a light Source and viewing lens for observation.
Endoscopes are inserted through the body orifices. Examples –rectum mouth or through small
incision (arthroscopy).
-
INDICATIONS
Endoscopy is used by doctors to evaluate:
Stomach pain
Ulcers, gastritis or difficulty swallowing
Digestive tract bleeding
Changes in bowel habits (chronicdiarrhoea or constipation).
Polyps or growths in the colon.
Biopsy
It can also be used to treat digestive tract problems and remove gallstones.
Nursing Interventions
-
Inform patient about the procedure
Patient should not take anything by mouth for 8 hours prior to the procedure
Serve prescribed sedatives before the procedure as well as atropine to reduce secretions.
Put patient in a left lateral position to facilitate clearance of pulmonary secretions and
provide smooth entry of the scope.
Monitor patients’ vital signs
Assess patient’s level of consciousness, oxygen saturation, pain level of after the
procedure.
Also check for signs of perforation (i.e. pain, bleeding unusual difficulty swallowing, and
rapidly elevated temperature.
Give throat lozenges, saline gargle and oral analgesic agents may be served if patient’s
gag reflex has returned.
To examine the colon, it must be cleared of stools with laxatives and copious fluids.
Complications of Endoscopy
-
Perforation (tear in the gut wall)
Reaction to sedation
Infection
56
-
Bleeding
Pancreatitis
SIGMOIDOSCOPY
This allows for direct visualization of the anus, rectum and sigmoid colon using sigmoidoscope.
It is used to diagnose suspected pathologic conditions of these organs.
It is recommended for patients who have had a change in bowel habits or obvious occult blood in
stool or who have severe lower abdominal pains.
Indications
- Colorectal cancer
- Colorectal polyp
- Ulcerative colitis
- Intestinal lschemia
- Biopsy of tumors
Contraindications
- Patients who are uncooperative.
- Patients with diverticulitis
- Painful anorectal conditions like haemorrhoids, fistula, fissures because of the pain associated
with the passage of the scope
- Patients with severe bleeding
- Patients suspected of having perforated colon lesions.
Procedure and Patient Care
Before
1. Explain the procedure to the patient.
2. Obtain an informed consent for this procedure
3. Assist the patient with bowel preparation. Two fleet enemas are sufficient for examining the
lower sigmoid colon and rectum.
4. Instruct the patient to ingest only a light breakfast on the morning of the procedure.
5. Assure patient that they will be properly draped to avoid unnecessary embarrassment.
During
1. The patient is placed on the endoscope table or bed in the lateral position.
Some Doctors prefer knee-chest position or lithotomy position.
2. Usually no sedation is required.
3. The anus is mildly dilated with a well-lubricated finger.
4. The rigid or flexible sigmoidoscope is placed into the rectum and advanced to its point of
maximal penetration.
5. Air is insufflated during the procedure to more fully distend the lower intestinal tract.
6. The sigmoid, rectum and anus are visualized.
7. Biopsy specimen can be obtained and polypectomy can be performed at the time of
sigmoidoscopy.
After
1. Inform the patient that because air has been insufflated into the bowel during the procedure he
or she may have flatulence or gas pains. Ambulation may help to bring it out.
2. Observe the patient for signs of abdominal distension, increased tenderness or rectal bleeding.
Tell the patient that slight rectal bleeding may occur if biopsy specimens have been taken.
57
NASO–GASTRIC TUBES
-
-
A nasogastric tube is a long polyurethane tube that is passed through the nasal passage
via the oesophagus in to the stomach, for diagnostic and therapeutic purposes Nasogastric
tubes are inserted by nurses, junior doctors and sometimes anaesthetists.
It is vital that staff inserting the tubes know the correct insertion technique as well as the
procedure for verifying their correct positioning.
Types of NG tube
1. Levin catheter; which is a single lumen, small bore NG-tube. It is more
appropriate for administration of medication or nutrition.
2. Salem sump catheter, which is a large bore NG tube with double lumen.
This avails for aspiration in one lumen, and venting in the other to reduce
negative pressure and prevent gastric mucosa from being drawn into the
catheter
3. Dobhoff tube, which is a small bore NG tube with gravity during insertion.
Some of the size are; 18 “(46cm), 22” (56cm), 26 “(66cm) and 30” (76cm)
from the distal end.
INDICATIONS
Diagnostic indications for NG intubation include:
Evaluation of upper gastrointestinal bleeding
- Aspiration of gastric fluid content
- Identification of the oesophagus and stomach on a chest radiograph
- Administration of radiographic contrast to the GI tract
(b) Therapeutic indications for NG intubation include:
-
Gastric decompression
Relief of symptoms and bowel rest in the setting of small bowel obstruction.
Aspiration of gastric content from recent ingestion of toxic material.
Administration of medication
Feeding
Bowel irrigation
NG tube can be kept following corrosive ingestion for the development of a tract in the
oesophagus that subsequently can be used for balloon dilatation.
Contraindications
1.
2.
3.
4.
5.
nasopharyngeal or esophageal obstruction
severe uncontrolled coagulopathy
severe maxillofacial trauma
Alkaline ingestion the tube may be kept if the injury is not severe
Strictures of the oesophagus
58
6. Anatomical abnormalities of the oesophagus
Advantages of passing NG tubes
Help in decompressing the stomach by releasing air and liquid contents. This is important
for patient with paralytic ileus, intestinal and gastric outlet obstruction. These conditions
can cause vomiting and patients are at risk of aspirating their stomach content, which can
lead to potentially lethal pneumonitis.
- NG tubes may also be useful for feeding patients who have dysphagia e.g. after
experiencing a stroke, and also for those patients who have undergone tracheostomy.
- Naso jejuna tubes are longer version of NG- tubes are inserted further in the jejunum and
may be useful in feeding patients with pancreatitis.
Requirement
Stethoscope.
Nasogastric tube (14 to l8size for adults; size 5-10 for children).
Water soluble lubricant
Gauze, cotton wool balls, cotton tip swab
Glass of water,
Adhesive tape
mackintosh cape and towel
Sizable syringe 20cc, Blue Litmus paper
Tongue depressor or mouth gag. (if patient is unconscious)
Kidney dish/emesis bowl
Non sterile gloves.
Drainage bag
Procedure
1. Wash hands and organize your equipment.
2. Explain procedure to client and provide privacy.
3. Send the prepared trolley to patient’s bedside.Place client in semi-fowlers position (facilitates
passage of tube into oesophagus instead of trachea.
4. Drape patient by covering the chest with the mackintosh cape and towel
5. Check and improve nasal patency by asking client to breathe through one nose (nostril) while
the other is occluded.
-Ask client to blow nose with both nares open.
- Clean mucus and secretion from nares with moist tissue or cotton wool tip swabs.
6. Measure the length of tubing needed by using tube itself as a tape measure. Measure distance
from tip of nose to earlobe, placing the rounded end of the tubing at earlobe measuring from
earlobe to sternal notch or xiphoid process Mark location of sternal notch along the tubing with
small marking.
7. Wash and dry hands and wear gloves
8. Dip the tip of feeding/nasogastric tube in water or lubricate the tip with local anaesthethetic
agent (xylocaine).
9. Ask patient to tilt head backwards and insert tube into clearest naris/nose.
10. As you insert tube deeper into nose tell client to hold head and neck straight and open the
mouth to breathe through.
11. When tube is seen and client can feel tube in pharynx, instruct client to swallow or give
several sips of water through a straw, or suck ice chips, unless contraindicated. Advance tube as
patient swallows
-
59
12. Insert tube further into esophagus as client swallows. Between attempts encourage client to
take deep breaths.
13. When tape mark on tube reaches entrance to flans, stop tube insertion and check placement
by
(a) Have client open mouth for tube visualization or to talk.
(b) Aspirate with syringe and monitor for gastric drainage or gastric content.
(c) Gastric contents are usually cloudy and green but may be off white, tan, bloody, or brown in
colour.
Gastric content could also be tested with a blue litmus paper for checking the acidity of the
stomach it changes it to red.
Secure the tube with tape and attach drainage bag OR cork the end if it is for feeding.
14. Wear gloves and administer oral hygiene and cleaning of tubing at nostril with normal saline.
15. Remove gloves, dispose of equipment and wash hands.
16. Begin suction or tube feeding as ordered.
17. Thank patient. Document the procedure
COMPLICATIONS
-
Nose bleeds
Sinusitis
Sore throat
Intracranial placement of the tube
Oesophageal perforation
Pulmonary aspiration
Collapsed lungs
Erosion of the nose where the tube is taped.
FEEDING A PATIENT THROUGH NASO-GASTRIC TUBE
Requirements;
A tray containing the following items;
Required amount of feed to be served,40cc or 50cc or 60cc of syringe,Gloves,Stethoscope or
litmus paper to determine correct position of the tube,Clean water in a cup,Small mackintosh and
towel or jaconet., Lips moisturizing lotion ,Input & output chart,Receiver,A screen
STEPS
Explains procedure to patient and provides privacy
Washes and dries hands
Sends prepared feed in a tray to patient's bedside
Makes patient comfortable and protects his (patient) clothing with a jaconet cap or small towel
and mackintosh
Wears gloves
Checks for proper placement of tube in the stomach by aspirating abdominal contents and testing
for acidity (pH) using lithmus paper OR inject 10-30cc of air through the tube and auscultate
epigastric region with a stethoscope and listens for the whooshing sound simultaneously
indicating proper positioning
Checks temperature of the feed by dropping a little amount on the back of hand
Pinches tube and removes spigot then flush with about 10-15 mls of water just before you start
feeding
60
Connects the feeding syringe to tube and pour the feed into the syringe. Release the pinch and
allows the feed to run by gravity
Ensures syringe never becomes empty completely to prevent air from entering patient’s stomach
Continues feeding till feed is finished
Flushes the tube with 10-15mls of water at the end of feeding
Pinches tube and removes syringe and replaces spigot
Removes protective clothing—jaconet cape or small mackintosh/towel
Applies lips moisturizing lotion if patient lips are dry
Makes patient comfortable, discards tray, washes hands and dry
Documents procedure on intake and output chart and into nurse’s note
REMOVAL OF NASO-GASTRIC TUBE
Requirements
Dressing mackintosh and towel,Tissue,Gloves,Receiver,Stethoscope (where
necessary),Cup with water,Clean gauze
PREPARATION
• Confirm the physicians order to remove tube
• Assist client into sitting position if condition permit
• Place dressing mackintosh and towel across patient chest to collect any spillage
• Provide tissue for client to wipe nose and mouth after tube removal
PROCEDURE
• Explain procedure and provide privacy
• Wash hands
• Detach the tube by removing the adhesive tape securing the tube to patient’s nose
• Put on disposable gloves
• Ask patient to take a deep breath and hold it.This closes the epiglottis thereby
decreasing the risk of aspiration.
• Pinch tube with the gloved hand thereby preventing the content in the tube from draining
into the throat.
• Quickly and smoothly withdraw the tube and place in a receiver
• Provide mouth care if desired and make patient comfortable
• Assess the drainage if suction was used and discard used items, wash and dry hands.
• Document findings.
• Thank patient.
Gastrostomy Feeding
Gastrostomy is a surgical creation of an opening into the stomach for the purpose of
administering foods and fluids.
This procedure can be done surgically while the patient is under general anaesthesia. A small
flexible, hollow tube with a balloon or special tip is inserted into the stomach through a small cut
on the left side of the belly area.
The surgeon uses sutures to close the stomach around the tube as well as the cut.
Classification
• Permanent
• Temporal
Indications
Babies with birth defects of the mouth, oesophagus or stomach e.g. Oesophageal atresia
or fistula.
61
Patients who cannot swallow due to cancer or tumour of oesophagus
Patients who cannot take enough food by mouth to stay healthy.
Patients who often breathe in food when eating.
Stricture of oesophagus caused by poison.
Following an operation of upper G.l.T
Requirements
A clean tray containing,A glass of drinking water,Required amount of feed,A sterile lubricant to
protect the surrounding area,A receiver,Mackintosh and towel,A syringe,Medicine as
ordered,Sterile dressings and forceps dressing tray,A clamp and sphigot,A funnel (sometimes)
Cape or napkin.
Procedure
Explain procedure to patient. Provide privacy.
Prepare and send trolley to the bed side of patient.
Place patient in a comfortable position.
Turn bed clothes as far back as necessary.
Place mackintosh and towel under patient to protect.
Wash hands and dry
Remove the spigot or a clamp from gastrostomy tube and attach the funnel when necessary.
Keep the tube pinched when spigot is removed to present air from entering the tube.
Aspirate gastric content with a syringe
Test for the acidity.
Pour water or flash the tube with water
Pour an amount of feed in a bowl or cup
Pass feed through the funnel in the tube
Always ensure that the funnel is not totally empty of feed before pouring another
Serve food/fluid in bits.
Do not force food/fluid through the tube
Intermittently flush tube with water
NB. Note amount of fluid given at a time
1f there is any prescribed medicines give after feeding by crushing it.
Flush tube with water after medication.
Disconnect the funnel.
Remove tray.
Apply sterile dressing on the wound when necessary.
Wash the used items.
Clean around the tube and the surrounding skin with sterile gauze
Apply a sterile ointment or a sterile lubricant around the wound.
Make patient comfortable in bed
Record and report findings.
After procedure.
Recording and Reporting
1.The type of feed.
2. The amount of food or fluid given.
3. The time.
4. Drug administration.
5. Specimen collected for investigation.
62
6. Auscultate the stomach to check for gas.
7. Report and record any adverse effect on the feeding.
Caring for the Gastrostomy tube site
-
Clean the skin around the tube 1 to 3 times a day with mild soap & water.
Remove any drainage or crusting on the skin & tube
Dry skin well with a clean towel
The site must be dressed with absorbent pad or gauze around the tube and changed
frequently.
Teach patient to report any of the following:
 If the stoma smells bad, there is pus draining from it or it is bleeding a lot
 If the stoma is changing in color, if it is getting longer, or it is pulling in to the skin.
 The skin around the stoma is bulging
 There is blood in the patient stools
 There is fever 38⁰C or higher or there is chills.
 vomiting
Complications
Reaction to medication
Problem breathing
Bleeding
Infection
COLOSTOMY
Is a surgical procedure that brings one end of the large intestine out through an opening (stoma)
made in the abdominal wall.
Stools moving through the intestines drain through the stoma into a bag attached to the abdomen
and usually on the left side.
- Colostomy may be short – term or long term(permanent or temporal)
- The colon, which is the first 4 or 5 feet of the large intestine, is part of the body’s
digestive system.
- It absorbs water from waste materials (faeces) and returns it to the body. It also absorbs
any remaining nutrients. The solid waste material is then passed through the colon to the
rectum, then to the anus for elimination.
When the colon, rectum, or anus is unable to function normally because of disease or injury, or
needs to rest from normal function, the body must have another way to eliminate the waste.
INDICATIONS OF COLOSTOMY
1. Colonic Cancer
2. Rectal Cancer (Some books or school of thought may put it together as Colorectal Cancers)
3. Injury to the colon or rectum e.g. (gun shot)
4. Diverticulitis
5. Partial or complete blockage of the large bowel
6. Crohn’s disease
7. Bowel incontinence
63
8. Imperforate anus
9. Diverticulitis
10.Tumors of the rectum
11.Abdomino-perineal resection
CLASSIFICATION OF COLOSTOMY
According to duration
1. Temporary colostomy
2. Permanent colostomy
According to location
1. Ascending colostomy
2. Transverse colostomy
3. Descending/sigmoid colostomy
Other forms classification
4. Doubled barreled colostomy (Wet colostomy, Dry colostomy)
5. Loop colostomy
6. single barreled colostomy
Types of pouches
1. Open-ended pouch
2. Close-ended pouch
3. One- piece pouch
4. Two-piece pouch
5. Pre-cut or cut-to-fit pouches
LOCATION
The location of colostomy depends on the reason for the surgery
1. Ascending colostomy: The colostomy is located on the right side of the abdomen
and stool is in liquid form
2. Transverse colostomy: The stoma is on the upper abdomen towards the middle
or right side. The stool may be loose or soft
64
3. Descending or sigmoid colostomy: The stoma is located on the left side of the
abdomen. Stools are semi-formed or formed(solid)
Colostomy can occur at any location along the colon but the most common site is the lower left
side near the sigmoid colon where majority of the colonic cancers occur.
DURATION
The duration can be temporary or permanent and the construction of the stoma as single or
double barrel.
1. Temporal; Sometimes used after surgery, injury or infection when a section of the colon
has been damaged.it may be in place for months, weeks or years. The temporary
colostomy is eventually closed and bowel movement returns to normal
2. Permanent; May be required if a section of the colon is severally damaged or both colon
and rectum are damaged due to cancer and or that matter cannot be used again.
It can also be classified as Single or Double Barrel
Other forms classification
Single barrel
The single barrel has got only one stoma (opening)
Double barrel
It has two openings (stoma); proximal and distal opening which is opened to the
abdominal wall. One opening is at the right side for stool and the other on the left side the lower
bowel for fluid. It can also be classified as; Dry and Wet Colostomy
Dry colostomy
The dry colostomy is opened onto the left side and empties Stools which are well formed or
solid.
Wet colostomy
The opening is mostly at the right side and the stool is mostly liquid. This is because it drains
urine and fluid from the intestine. It is done for patients who have problem the kidney where
there is transportation of the ureters into the Colon.
Preparation of patient for colostomy
Explain procedure to patient
Obtain a signed consent form
Investigations such as blood,x-ray,urine,electrocardiogram etc. ordered by the doctor must be
carried out
Patient may be placed on a low residue diet for several days prior to the surgery to cleanse and
empty the bowel
Fluid diet should be given at least a day before the surgery with nothing by mouth after midnight
Enaema or oral preparations (laxatives) may be ordered to empty the bowel
Oral anti infectives (neomycin,erythromycin etc.)may be ordered to decrease bacteria in the
intestine and help prevent post-operative infections.
Intravenous fluids may be set up if ordered by surgeon
Nasogastric tube is passed on the day of surgery to remove gastric secretions and prevent nausea
and vomiting
65
Urinary catheter may be passed to keep the bladder empty during surgery and also decrease the
chance of accidental injury
Teach patient deep breathing and coughing exercise
Post-operative care
Monitor vital signs every 15 minutes for the first hour,then 30minutes for 2 hours,then hourly for
4 hours until patient’s condition is stable
Intravenous fluids are given until bowel sounds are heard or patient has passed flatus
For the first 24-48 hours after surgery,the colostomy will drain bloody mucus. Make sure you
apply a colostomy bag to control odour
Instruct patient to supportthe operative site during deep breathing and coughing
Serve prescribe analgesics and antibiotics as ordered
Observe wound site for colour and amount of wound drainage
Monitor fluid intake and output
Encourage early ambulation (24 hours post-operatively)
Irrigation of the colostomy is done on the 5-6 day post-operatively
Continuously monitor client’s urinary output
Encourage patient to take in a lot of fluids and fluid diets
The stoma and the area around the colostomy should be washed with soap and water, dried, and
zinc oxide cream applied to the skin to prevent any irritation after changing the colostomy bag
Note: Usually stool is liquid and gradually thickens as the patient begins to take solid foods.
Pouches
They are placed over the stoma to collect the faeces that normally would pass through the rectum
and anus.Pouches are lightweight and odour proof and have a special covering that prevents the
pouch from sticking to the body. Some pouches also have charcoal filtered which releases gas
slowly and help to decrease gas odour. They come in variety of sizes and styles
Types of pouches
Open ended pouch: opening is at the bottom which allows the pouch to drain its contents. The
open end is usually closed with a clamp.it is usually used by people with ascending or transverse
colostomies. The stools are looser and more unpredictable
Closed ended pouch: this type of pouch is removed and thrown away when the pouch is filled.
Stools in this region are usually solid/firm and are usually used by people with a descending or
sigmoid colostomy
One piece: a one-piece pouch contains the pouch and adhesive skin barrier together as one unit.
The adhesive skin barrier is the part of the pouch system that is placed around the stoma and
attached to the skin. When the pouch is removed and replaced with a new one, the new pouch
must be having adhesive skin barrier for reattachment to the skin.
Two pieces: it has two parts; an adhesive flange and pouch. The adhesive flange stays in place
while the pouch is removed and new pouch is attached to the flange
The pouch does not need to be reattached to the skin each time. The two-piece system can be
helpful for patient with sensitive skin
Precut or cut to fit pouches: some pouches have precut holes. Other pouches can be cut to fit the
size and shape of the stoma. Cut to fit pouches are especially useful right after your surgery
because stoma decreases in size after about eight weeks
Colostomy care
It involves the maintenance of hygiene by regular emptying of colostomy bag and cleaning of the
colostomy site.
66
Purposes of care
Prevent leakage
Prevent excoriation of the skin and stoma
Observe stoma and surrounding skin
Care of colostomy
Requirements
Mackintosh and Towel,Disposable and sterile gloves,Gauze swabs,Water,Mild soap in a
dish,Disposable colostomy bag with clamp,Stoma measuring guide,Zinc oxide ointment,(Skin
barrier)Bedpan with cover,Screen
PROCEDURE
Explain procedure to patient
Assemble the necessary equipment
Washand dryhands and don gloves
Provide privacy and assist client to a comfortable position(fowlers,semi fowlers or sitting
position)
Empty the partially filled pouch into bedpan if it is a drainable pouch
Remove the pouch slowly beginning at the top while keeping the abdominal skin firm
Use gauze to remove excess stool from the stoma and cover the stoma with gauze
Gently wash with mild soap and dry the peristomal skin by patting gently
Assess the appearance of the peristomal skin and stoma. A moist reddish pink stoma is
considered normal
Apply skin barrier (zinc oxide) and allow the paste to dry for 1-2 minutes
Apply the skin barrier and appliances together
Pouch preparation
Select the size of stoma opening by using the measurement guide
Trace same size circle on the back at the centre of the skin barrier
Use scissors to cut an opening ¼ or 1/8 inch larger than the stoma
Remove the backing to expose the sticky side
Ease barrier and pouch over the stoma and gently press unto the skin while smoothing out
creases or wrinkles. Hold the pouch in place for 5 minutes
Instill aspirin in bag to prevent odour
Close the pouch if it is drainable by folding the upper end upwards and using a clamp or clip
Dispose of used equipment, discard gloves and wash hands
Document appearance of stoma, condition of peristomal skin and client’s reaction to the
procedure
COLOSTOMY IRRIGA TION
Irrigation is best achieved with descending or sigmoid colon colostomy whiles the transverse and
the ascending is done with difficulties because of its anatomic position.
Purposes
1. To drain the colon of its content — faeces, gas and mucous.
2. To clean the lower intestinal tract.
67
3. To establish regular pattern of evacuation so that normal life activities could be established.
REQUIREMENT
 A jar for irrigating fluid.
 An irrigating can.
 An enema.
 An irrigating fluid mostly Normal
 Saline (N/S).
 A tubing and clamp.
 A catheter mostly 22-24 size.
 An irrigating sleeve.
 A plastic bag to collect soiled dressings.
 A colostomy bag.
 A lubricant.
 Toilet tissues.
 Colostomy deodorant.
 Disposable bag,
PROCEDURE
1. Select a suitable time preferably after meals so that this time fits into patient post hospital
pattern of activity. Irrigation should be done at the same time each day.
2. Hang irrigation can with solution 45-50cm above the Stoma or shoulder height of patient.
3. Make patient sit in front of toilet commode or a closet and explain procedure in detail.
Provide privacy and remove colostomy bag and place in a plastic bag.
4. Apply an irrigation sleeve into the stoma and direct one end to the commode or closet.
5. Allow some of the Solution lo flow through the tubing and the catheter or cone.
6. Lubricate the catheter or the cone anti insert up to about 3 inches into stoma.
7. Hold the catheter gently against the stoma to prevent backflow.
8. Never force cone or catheter into stoma and after N/S has been introduced into the stoma,
wait for about 15 minutes for a return flow.
9. Clean the peristomal skin and the stoma.
10. Apply zinc oxide or barrier cream.
11. Replace colostomy bag.
12. Spray the room with air freshener.
13. Remove and discard equipment.
14. Clean equipment with soap and water.
15. Report and record your findings.
DIET FOR A COLOSTOMY PA TIENT
Patient with colostomy will take adequate nourishment (nutrition) but free of gas producing
foods and irritant foods such as egg, beans, milk, cabbage etc. and spices, acidic foods, alcohols
etc.
Food should be Semi-solid or semi-liquid to regulate/ control passage of stool. Avoid the use of
alcohol beverages.
Patient must eat high fibre diet to prevent constipation
Encourage fluids: drink at least 8 to 10 cups of water each day
68
Educate patient to identify and avoid foods that cause gas and odour. Some vegetables such as
broccoli,cabbage and cauliflower.
COMPLICATIONS
1.
2.
3.
4.
5.
6.
7.
8.
Bleeding
Infection
Ischemia
Leakage around the stoma
Injury to surrounding organs during the procedure
Rectal discharge of mucous
Prolapse or retraction of the stoma
Obstruction of the stoma
AREAS TO AVOID STOMA POSITIONING
1.
2.
3.
4.
5.
6.
7.
Areas affected by skin condition
Boney prominences
Skin folds
Site of surgical incision
Site that cannot be seen by the patient
Umbilicus
Waist line
ILEOSTOMY
An ileostomy is opening into the ileum (small bowel).An ileostomy produces liquid
faecal drainage. Drainage is constant and cannot be regulated.ileostomy drainage contains
some digestive enzymes which are damaging to the skin. For this reason, patient must
wear an appliance continuously and take precautions to prevent skin breakdown
CARE
Usually, the patient is given a low-residue diet, provided in frequent, small feeding
Patient with ileostomy cannot establish regular bowel habits because the contents of the
ileum are fluid and are discharged continuously. The patient must wear a pouch at all
times. Stomal size and pouch size vary initially; the stoma should be rechecked 3 weeks
after surgery, when the edema has subsided.
Usually, the ileostomy stoma is about 2.5 cm (1 in) long, which makes it convenient for
the attachment of an appliance.
DIET
A low-residue diet is followed for the first 6 to 8 weeks.
Strained fruits and vegetables are given. These foods are important sources of vitamins A
69
and C and also avoid foods that are high in fiber or hard to digest kernels, such as celery,
popcorn, corn and coconut, which may result in a stomal obstruction.
Advise the patient to avoid food products with cellulose such as nuts/ seeds because they
are nondigestible residue of plant foods and they also hold water, provide bulk, and
stimulate elimination.
Advise patient to take in moderation fruits like grapes, bananas because they increase the
quantity of effluent.
Complication

Stricture of the stoma

Flatulence

Faecal irrigation

Fluid and electrolyte imbalance

Intestinal obstruction
CHAPTER FIVE
NURSING CARE OF PATIENTS WITH FEMALE REPRODUCTIVE PROBLEMS
Identification of various instruments for gynaecological examination
Ayre's Spatula
Is used for taking Pap smear for screening of carcinoma cervix.
Made of wood so that cells can adhere to its porous surface.
The long end is inserted into cervical canal and rotated in 360 degrees.
The exfoliated cells obtained are smeared on glass slide and fixed in Koplicks jar which contains
ether and alcohol in equal amount. The other broad end is used for obtaining cells from lateral
vagina for knowing the hormonal status.
Babcock's Forceps
This instrument is used for grasping tubular structures like fallopian tube. The tip is atraumatic as
there is no sharp tooth.
Cusco's Speculum
Self-retaining double bladed vaginal speculum and its used for routine examination,taking of Pap
smear,insertion and removal of Copper T.
Doyen's Retractor
For retracting bladder during abdominal operations like laparotomy.
Foleys Catheter
This is a self-retaining catheter most commonly used for drainage of the urinary bladder after
surgery.
Hegar's Dilator
It’s a long rod like instrument with gentle curve and tapering tip.For dilatation of the cervix in
procedures like D&C.It can cause perforation if too much force is used. Very large dilatation can
cause cervical incompetence.
70
Karman's Syringe (Menstrual Regulation)
This syringe is used for Menstrual Regulation and endometrial aspiration. The capacity is 50 ml.
The tip has a rubber attachment with valve.
The piston when withdrawn can be locked. It creates negative suction. To the rubber attachment
at the tip, plastic cannula is attached and is inserted in uterine cavity. The valve is released and
with negative pressure contents of the uterine cavity are sucked. This should be repeated till the
cavity is empty. Complication of the procedure is incomplete evacuation because of limited
suction pressure.
Rubin's Cannula
This cannula is used for tubal patency test for infertility like HSG (Hysterosalpingography).In
HSG radio opaque iodine (Urographin) is used (it is colorless to naked eye but on x ray is seen as
opaque white).
Pinard's Fetal Stethoscope
This is used for auscultation of fetal heart. The tapering rim is applied to ear and the other side to
mothers’ abdomen.
With other instruments available for auscultation of fetal heart, this is now rarely used.
Sims' Anterior Vaginal Wall Retractor
This instrument is used with Sim's Speculum. It’s a long instrument with blunt loops at both the
ends making an angle for easy visualization of cervix and vagina, especially useful in case of
cystocele.
Sims' Speculum
Sims Speculum is used for inspection of vagina and cervix. is not self-retaining. It retracts
posterior vaginal wall.
For complete visualization anterior vaginal wall retractor must be used.
Used for taking Pap Smear, Insertion and removal of Copper T, Colposcopy, Taking swabs,
Hysterosalpingography (HSG).
Sponge Holder / Sponge holding forceps
For holding sponge or a gauze piece for painting the area before operation.
Suction Curette
This instrument is used for first trimester MTP, suction of vesicular mole. It is numbered as per
outer diameter. The size of the cannula selected is equal to no of weeks of pregnancy. The tip is
blunt (to prevent perforation) below the tip are two sharp openings for suction and curetting the
cavity. Usually suction force of 60 mm Hg is applied. Rotational and in & out movements are
done to empty the cavity. Grating sensation and gripping of the cannula indicates the procedure
is complete.
Shirodkars Cerclage Needle
This is specially designed needle for putting stitch around the cervix. The needle is inserted
around the cervix through the opening made in vagina.
Trocar and Cannula
Trocar is put in to the cannula and then inserted into abdominal cavity for laparoscopy.Uterine
Curette
Use for scraping endometrial cavity to obtain sample for histopathology. The tip is angled by
about 15 degrees for easy scraping.
The tip comes in two shapes. Sharp and Blunt. Sharp curate is used in gynecology and blunt in
pregnancy check curettage.
Uterine sound
71
It is a long instrument with blunt tip (To avoid perforation) about 5 cm from the tip its bend to
make angle of 30 degrees.
It has marking on it for measurements. (Bladder sound has no markings)
The angle helps to negotiate curvature of the uterus (Anteflexion). It is used for measuring
uterocervical length, length of the cervix (for diagnosing supra vaginal elongation of the cervix),
to feel for any pathology inside the cavity like fibroid, Congenital anomalies like septa or
bicornuate uterus, Adhesions and to feel for the misplaced IUCD.
Bladder Sound
It is long instrument with gentle curve (not angled like uterine sound) and has no markings on it.
It is used to define extension of bladder cystocele and vaginal hysterectomy.
Vulsellum
This instrument is used for grasping the cervix (Usually anterior lip of the cervix is grasped)
It is a long instrument with gentle curve so that the line of vision is not obstructed. The tip of the
blades has 3-4 teeth to hold and steady the cervix in procedures like Insertion of IUCD, D&C.
Since the teeth are sharp it is not used in pregnancy as it may cause cervical tares and lacerations.
Instead sponge holding forceps is used to grasp the cervix.
Tenaculum
This instrument is straight instrument and has only single bite for grasping the cervix.
It is used for Hysterosalpingography, Hysteroscopy etc.
PREPARING A PATIENT FOR GYNAECOLOGICAL EXAMINATION
Definition:
Gynaecological examination is the assessment of the female reproductive system both
internally and externally including the breast.
Indication:




Infections or irritations of the female reproductive system.
To promote comfort after gynaecological examination or operation.
After delivery.
Before female catheterization.
General requirements
A trolley with top shelf:







Sterile speculum in a covered receiver.
Sterile gallipot with swabs.
Sterile applicator.
Sterile sponge holding forceps.
Sanitary pad opened.
Lotion in sterile gallipot.
Sterile spatula.
72

Sterile towel.
Bottom shelf:











Receiver for used swabs.
Covered bed pan.
Gloves both examination and sterile.
Bottle of lotion.
Lubricant e.g. KY jelly.
Closed test tube for sterile applicator.
A jug of hot water.
A receptacle for used instrument.
Mackintosh and cover or paper towel.
Clean bed lining.
Receptacle for soiled linen.
Preparation before the procedure.
-
Before making any examination, it is essential that careful history is taken such as: name,
age and address.
A brief statement of the general nature and duration of the complaint.
Obstetric history - number of children with their ages, any abnormalities during pregnancy
(abortion).
Usual menstrual cycle - age of menarche, regularity of the cycle, length of cycle.
Previous medical history — details of any serious illness or operation.
- History of present complains:
a) Any abnormal menstrual loss
Amount of loss -is it more or less than the usual?
Any pain?
b) Is there any pelvic pain, ask of the site, the nature of the pain and ask if there is anything
that aggravate it or reliefs it.
C) Any vaginal discharges- If there is, ask of the amount, colour, odour and presence of
blood.
Any emotional problems- tactfully enquire any relationship with her husband or sexual partner.
- Explain the procedure of the examination to the client and what she should expect in the
examination.
- If possible, the equipment to be used can be shown to her to reduce anxiety. Assure her
of confidentiality of all findings from the examination.
73
-
Provide privacy.
Ensure urinary bladder is emptied
It is necessary she takes her bath and the vulva well washed especially for vaginal
examination
If the client is confined to bed and personal hygiene becomes a problem, the nurse would
have to wash her if it becomes necessary.
Help or put her into right position for the particular type of examination.
For vaginal or pelvic examination, dorsal, lithotomy, sim’s, knee chest can be used.
For breast examination, the client may be sitting or lying in recumbent or dorsal
position.
Explain to her how to loosen the pelvic floor muscles during pelvic examination
CARE AFTER PROCEDURE






Put patient into comfortable position.
Educate patient on personal hygiene and also preventive and curative measures on her
condition.
Thank and congratulate patient.
Discard equipment and decontaminate for sterilization.
Wash and dry hands.
Record and report findings made.
Complication
Pain
Bleeding in some cases.
Pelvic Exam
A pelvic exam is a visual and physical examination of a woman's reproductive organs.
Women should have their first pelvic exam at age 21, unless other health issues require it
earlier.
Avoid vaginal intercourse, inserting anything into your vagina, and douching, at least 24
hours before your pelvic exam.
During the exam, the doctor inspects the vagina, cervix, fallopian tubes, vulva, ovaries,
and uterus.
There are no specific guidelines for how often a woman should have a pelvic exam, but it
is often recommended to have one once a year. Depending on a woman’s medical history,
a doctor may suggest that you have them more frequently. Women should have their first
pelvic exam at age 21 unless other health issues require it earlier.
74
Indications



unusual vaginal bleeding or discharge
a family history of cancer
concern about ovarian cancer, cysts, sexually transmitted diseases, and other
gynecological problems
Preparing for a Pelvic Exam
-
Make sure to set your pelvic exam for a date when you will not be on your period.
Avoid vaginal intercourse, inserting anything into your vagina, and douching, at least 24
hours before your pelvic exam.
Change patient’s clothing into a gown.
The woman is placed in lithotomy position.
Inspection of external genitalia.
Vaginal examination is done to rule out abnormalities of the birth canal and to obtain
cytologic smear for gonorrhea, vaginal trichomoniasis, candidiasis, herpes etc.
Examination of the cervix for position, size, mobility, and consistency. Cervix is
softened and bluish (increased vascularity) during pregnancy.
Identification of the ovaries (size, shape, and position).
Rectovaginal exploration to identify hemorrhoids, fissures,swelling, or masses.
PAP SMEAR
Pap smear of the cervix is obtained during pelvic examination to screen for cervical cancer. May
also help to detect endometrial cancer, infections, It tests for the presence of precancerous or
cancerous cells on the cervix, the opening of the uterus. It is named after the doctor who
determined that this was a useful way to detect signs of cervical cancer, GeorgiosPapanikolaou.
Detecting cervical cancer early with a Pap smear gives a greater chance at a cure.Detecting these
abnormal cells early with a Pap smear is your first step in halting the possible development of
cervical cancer.Generally, you should start getting regular Pap smears at age 21.
Recommend testing every 3 years from ages 21–65years.
Indications for Pap Smear
-
-
1.
2.
3.
All sexually active women are at risk for contracting HPV and should get a Pap smear at
least every three years.
HIV-positive or those who have a weakened immune system from chemotherapy or an
organ transplant, may need more frequent tests because of a higher risk of infections and
cancer.
Those in monogamous relationship. This is because the HPV virus can be dormant for
years, and then suddenly become active.
Preparation for Pap smear
Book an appointment with the gynecologist.
Procedure is explained to the patient and reassured.
Patient changes her cloths into a hospital gown.
75
4. Ask patient of any medicine usage such as contraceptives containing oestrogen and
progesterone because it may affect test results.
5. Ask patient if she has had an abnormal pap smear or if pregnant
6. Educate patient not to douche, have sex or use tampons 24hrs before procedure.
7. Tell patient that this procedure is avoided when menstruating.
8. Tell patient to empty bladder before procedure
9. Instruct patient not to use cream in the vagina 48 hours before the examination.
REQUIREMENTS
Top shelf
•
•
•
•
Sterile towel
Drape
Speculum
Cervical spatula
Gallipot with antiseptic lotion
Gallipot with cotton wool swab
•
•
•
•
Lower shelf
sterile Gloves
Receiver
Mackintosh and towel
Sample bottle
Procedure
-
Explain procedure to patient
Provide privacy
Put patient in supine, dorsal lithotomy position
Wash hands and dry
Put on sterile gloves
Clean the vulva inside and around to reduce microbial load
Lubricate speculum with sterile lukewarm water
Insert the speculum in the vagina to examine the cervix
Cervical spatula with a small brush is inserted into the cervix to collect sample of tissue
from the cervix
Remove spatula from cervix and place it into the specimen bottle with liquid
Label bottle and send to laboratory.
Clean the vulva again
Make patient comfortable
Discard trolley and decontaminate equipment
Remove screen
Wash and dry hands
Report and document any findings
After Care
1. If the pap’s smear has induced some bleeding provide patient with a sterile gauze or pad as
a liner in the pants.
76
2. Inform patient that she will be notified of the results by her physician later after the test has
been done.
COMPLICATIONS
-
Minor bleeding
Infection.
HYDROTUBATION (TUBAL FLUSHING)
Is a process whereby saline solution containing dye is introduced into the fallopian tube to
determine patency.
This type of insufflation performed on women when they are in their ovulation period.it is done
to open the fallopian tubes to correct abnormalities which will enable a woman conceive after
sex.
REQUIREMENTS
• A tray containing;
• Cusco’s vagina speculum (used to open the vagina).
• Vuselum forceps (used to hold the cervix).
• Sponge holding forceps (for washing the vulva).
• Syringe and needle
• Sterile gloves
• Sterile gauze
• Gallipot
• Antiseptic lotion
• Stethoscope (for checking heart beat or listening to cavities in the body)
PREPARING A PATIENT FOR HIGH VAGINAL SWABBING
A high vagina swab is taken from the vault of the vagina for culture and sensitivity.
Requirements
A trolley with the following;
Top shelf;
• Sterile vaginal speculum
• Sterile swabs in sterile test tubes
• Gallipot with lotion
• Cotton wool in a sterile gallipot
Bottom shelf;
• A lubricant e.g. K.Y jelly
• Gloves
• Mackintosh
• Receiver
Preparation of patient before procedure
• Explain procedure to patient
• Provide privacy
• Ask patient to empty bladder
77
•
•
•
•
•
Help patient in dorsal position and the knees flexed,vulva exposed
Protect bed with mackintosh or water proof sheet and towel
Washand dry hands and don gloves
Swab the vulva with sterile swab
Lubricate and insert speculum into the vagina to separate vaginal walls,insert speculum
sideways.turn speculum ,open it and tighten the screw
• Remove swab from the tube and insert it into the vagina
• Take swab as high as possible in the vaginal vault
• Remove swab and put it into its container
• Unscrew speculum to close it, turn it sideways and withdraw and place it in the receiver
• Clean vulva and leave patient dry
• Remove mackintosh and towel
• Remove glove
• Make patient comfortable and thank patient
• Discard the equipment
• Wash and dry hands
• Label and ensure specimen is sent to the laboratory with the signed request form
• Record and report observation
COMPLICATION
Pain
HYSTEROSALPINGOGRAPHY
This fluoroscopic x-ray study of the uterus and fallopian tubes is used to determine tubal
patency, detect pathology in the uterine cavity, and identify peritoneal adhesions, and for
treatment of unexplained fertility.
A bivalve speculum is introduced while patient is in the lithotomy position and contrast medium
is injected into the uterine cavity; the medium will enter the peritoneum in 10 to 15 minutes if
tubes are patent.
Is similar to a pap smear except a small catheter is inserted into the opening of the cervix so that
a contrast can be injected. The contrast helps to see the female reproductive system on x ray.
Nursing Care
1. Determine date of last menstrual period; the test is done a few days after menses ends, before
ovulation. Obtain pregnancy test if patient is within childbearing years, as indicated.
2. Verify that the patient does not have a history of allergy to contrast media or iodine.
3. Administer prescribed antibiotic and analgesic.
4. After procedure, apply perineal pad for drainage of excess contrast medium or blood and
instruct patient to notify physician if bloody drainage continues after 3 days or if signs of
infection are present.
5. Inform patient that pain medication may be necessary for shoulder discomfort because of dye
irritation of the phrenic nerve.
BREAST EXAMINATION
Is a method of screening used to detect early breast cancer
78
Breast examinations are performed for a number of clinical reasons patient, usually female, may
present with mastalgia (breast pain), nipple changes (shin or discharge) or more commonly a
breast lump. Due to this fact it is commonly examined upon, as it is an important skill to know.
As this is an intimate examination, it is pertinent to gain a good rapport with your patient,
maintain good communication and ensure the patient’s dignity at all times
Method of palpating the breast for lumps
Vertical pattern; it involves moving the fingers up and down of the breast
The pie wedge pattern; this starts at the nipple and move outwards
Circular pattern; it involves dividing the breast into four quadrant and checking each quadrant
separately
Steps
1. Wash hands
2. Introduce yourself to the patient and clarify their identity. Explain to them what the
examination will entail and gain the patients consent
3. Provide privacy
4. Expose patient from waist up
5. Ask patient of any history of breast masses, pain or tenderness in the breast, discharge
from the nipple.
6. Ask patient of any medication history because some medications such as oral
contraceptives, steroids, digitalis and diuretics may cause nipple discharge
7. Inquire also from patient of oestrogen replacement therapy because it may lead to the
development of cysts or cancer, risk factors that may also lead to the development of
breast cancer (e.g., mother, sister, aunt with breast cancer; alcohol consumption, high-fat
diet, obesity, use of oral contraceptives, menarche before age 12, menopause after age 55,
age 30 or more at first pregnancy).
8. Inquire if the client performs breast self-examination; technique used and when
performed in relation to the menstrual cycle.
9. Inspect the breasts for size, symmetry, and contour or shape while the client is in a sitting
position.
10. Inspect the skin of the breast for localized discolorations or hyperpigmentation,
retraction or dimpling localized hypervascular areas, swelling or oedema
11. Emphasize any retraction by having the client
- Raise the arms above the head,
- Push the hands together, with elbows flexed.
- Press the hands down on the hips.
12. Inspect the areola area for size, shape, symmetry, color, surface characteristics, and any
masses or lesions
13. Inspect the nipples for size, shape, position, color, discharge, and lesions
Palpate the axillary, subclavicular, and supraclavicular lymph nodes while the client sits with the
arms abducted and supported on the nurse's forearm.
79
14. Palpate the breast for masses, tenderness, and any discharge from the nipples. Palpation
of the breast is generally performed while the client is supine because in the supine
position, the breasts flatten evenly against the chest wall, facilitating palpation.
For clients who have a past history of breast masses, who are at high risk for breast cancer, or
who have pendulous breasts, examination in both a supine and a sitting position is recommended.
If the client reports a breast lump, start with the "normal" breast to obtain baseline data that will
serve as a comparison to the reportedly involved breast.
To enhance flattening of the breast, instruct the client to abduct the arm and place her hand
behind her head. Then place a small pillow or rolled towel under the client's shoulder.
For palpation, use the palmar surface of the middle three fingertips held together and make a
gentle rotary motion on the breast.
Start at one point for palpation, and move systematically to the end point to ensure that all breast
surfaces are assessed.
Pay particular attention to the upper outer quadrant area and the tail of Spence
.
15. Palpate the areola and the nipples for masses. Compress each nipple to determine the
presence of any discharge.
If discharge is present, milk the breast along its radius to identify the discharge-producing lobe.
16. Assess any discharge for amount, color, consistency, and odor. Note also any tenderness on
palpation.
17. Teach the client the technique of breast self-examination
18. Document findings in the client folder.
CHAPTER SIX
NURSING CARE OF PATIENT WITH MALE REPRODUCTIVE PROBLEMS
URETHRAL SMEAR
Smear:It is a specimen for microscopical examination that has been prepared by spreading a thin
film of material across a glass slide.
Urethral Smear:It is the taking of specimen from the urethral for microscopical examination.
INDICATIONS
1. When there is discharge from the urethral
2. To diagnose Sexual transmitted Infections example, Gonorrhoea, syphilis
REQUIREMENTS
TOP SHELF


Sterile gloves
Sterile cotton
LOWERSHELF

Solutions example normal saline, distilled water
80




Receiver
Specimen tube
Mackintosh with towel
Request form
PREPARATIONS OR CARE BEFORE PROCEDURE



Inform patient about the procedure
Tell patient not to pass out urine 1hour before the procedure
Tell patient not to take too much fluids before procedure
PROCEDURE OR STEPS FOR MALES
 Explain procedure to patient
 Provide privacy
 Wash and dry hands
 Put patient in a comfortable position
 Ask patient tactfully to expose his genital area and cover with towel
 Wash and dry hands and put on gloves
 Clean the openings of the urethral (the tip of the penis with sterile cotton and solution)
 Retract glans penis to obtain maximum visibility of the area for the swab
 Rotate the tip of the swab gently for about ¾ inches into the urethra and collect the
specimen
 Retrieve swab and put back into the specimen tube
 Remove gloves
 Make patient comfortable in bed and congratulate him for his co-operations
 Remove screen
 Discard and decontaminate equipment for sterilization
 Wash and dry hands
 Label and ensure specimen is sent to the lab
 Record and report any findings
CARE AFTER PROCEDURE
 Tell patient to urinate
 Check for any signs of pain or fainting
 Check for haemorrhage
COMPLICATIONS
 Fainting(cause by stimulates of the vagal nerve)
 Haemorrhage
 Infections
81
PROCEDURE OR STEPS FOR FEMALES


















Explain procedure to patient
Provide privacy
Wash and dry hands
Ask patient to expose her genitalia area and cover with a towel
Put patient in a dorsal recumbent position with kneel flexed and vulva expose
Put mackintosh and towel under patient to protect bed
Wash and dry hands and put on sterile gloves
Perform vulva toileting by cleaning both labia majora and minora with distilled water
Use the forth and thumb to separate both majora and minora to expose urethra orifice
Rotate swab tip gently for about 2/4 inches into the urethral and collect specimen
Retrieve swab and put back into specimen tube and cover it
Remove gloves
Make patient comfortable in bed and congratulates her for her co-operations
Remove screen
Discard trolley and decontaminate instruments for sterilization
Wash and dry hands
Label and ensure specimen is sent to the lab with signed form
Record and report any findings
CARE AFTER PROCEDURE
I.
II.
III.
Tell patient to urinate
Check for any signs of pain
Check for haemorrhage
COMPLICATIONS
Fainting
Infections
Haemorrhage
CHAPTER SEVEN
NURSING CARE OF PATIENTS WITH MUSCULOSKELETAL PROBLEMS
Preparation of patient for orthopaedic surgery
•
•
•
•
Prepare patient physically, psychologically and socially to overcome anxiety.
Orientate patient and relatives to the prostheses center in case of the need for a
prostheses.
Educate patient on breathing, joint and muscle exercise.
Educate patient on how to use bedpan, urinal and other bed accessories before
operation.
82
•
Prepare skin area of operation including area above and below the joint on the
affected side.
• Shave patient where necessary to minimize infection.
• Ensure laboratory investigation such as FBC, grouping and cross matching and chest
x-ray are explained to the patient.
• Obtain a signed consent form
• Serve prescribed medication such as sedative or analgesic.
PRINCIPLES OF FRACTURE MANAGEMENT
1. Resuscitation
2. Reduction — correction or realignment of the fractured bone by traction, pulling.
- Open or closed reduction.
3. Restriction on movement — splinting, P.O.P, bandaging.
4. Restoration of function (treatment) — using zimmer frame, crutches, walking aids
5. Rehabilitation.
PRE-OPERATIVE MANAGEMENT FOR ORTHOPAEDIC SURGÈRY
Psychological care
Explain procedure
Reassurance
Orientate patient the limb fitting Centre in case there is the need for prosthesis.
Physical Preparation
Mainly the skin preparation
Shave, wash the affected area. if there is wound, dress it. Observe area to rule out infections and
lesions.
Catheter must be passed if needed.
Change patient’s attire into theatre dress or gown, and hair net/cap/cover if a
woman.
Maintain good personal hygiene on the morning of surgery.
Ask patient to void and empty bowel.
Vital signs must be monitored and corrected.
Educate patient on breathing, joint and muscle exercise.
Educate patient on how to use bed pan, urinal and other bed accessories e.g. air ring, pulley
before operation.
Physiological preparation
Various investigations should be done to rule out any infections of WBC, RBC,
AB, urine RE, wound swabs
TRACTION
Traction is the process of exerting a pulling force on portions of the bone by means of pulleys
and or weights.
Purposes of Traction
1. To reduce and immobilize fracture.
2. To regain normal length and alignment of an injured
extremity.
3. To lessen or eliminate muscle spasm.
4. To prevent deformity.
5. To give the patient freedom for “in-bed” activities.
6. To reduce pain.
83
Types of Traction
Running Traction:A form of traction in which the pull is exerted in one plane. May use either
skin or skeletal traction.eg. Buck’s extension traction
Balanced Suspension Traction:Uses additional weights to counterbalance the traction force and
floats the extremity in the traction apparatus.The line of pull on the extremity remains fairly
constant despite changes in the patient’s position.
Application of Traction
Traction may be applied to the skin or to the skeletal system
Skin Traction:Accomplished by applying a light force that pulls on tape, sponge rubber, or
special device (boot, cervical halter, pelvic belt) that is in contact with the skin.The pulling force
is transmitted to the musculoskeletal structures.Skin traction is used as a temporary measure in
adults to control muscle spasm and pain.It is used before surgery in the treatment of hip fracture
(Buck’s extension) and femoral shaft fractures (Russell’s traction).It may be used definitively to
treat fractures in children.
Skeletal Traction:Traction applied by the orthopedic surgeon under aseptic conditions using
wires, pins, or tongs placed through bones and provides a strong, steady, continuous pull.Skeletal
traction is used most frequently in treating fractures of the femur, humerus (supracondylar
fractures), tibia, and cervical spine.
Complications of traction
1. Infection of pin tracts in skeletal traction.
2. Skin breakdown and dermatitis under skin traction.
3. Neurovascular compromise resulting in increased pain,muscle spasms, numbness, tingling,
and loss of sensation.
4. Inadequate fracture alignment resulting in posttreatment arthritis.
5. Complications of immobility includingThrombophlebitis,Pressure ulcers,Urinary infection and
calculi,Constipation.
Nursing Assessment
1. Assess for pain, deformity, swelling, motor and sensory function,and circulatory status of the
affected extremity.
2. Assess skin condition of the affected extremity, under skin traction and around skeletal
traction, as well as over bony prominences throughout the body.
3. Assess for alignment of affected body part.
4. Assess for signs and symptoms of complications.
5. Assess traction equipment for safety and effectiveness by
placing patient on a firm mattress,ropes and the pulleys should be in alignment,the pull should
be in line with the long axis of the bone,
Any factor that might reduce the pull or alter its direction must be eliminated such as the Weights
should hang freely,Ropes should be unobstructed and not in contact with the bed or
equipment,Patient’s bed should have an overhead trapeze set up to assist the patient to move in
bed at frequent
Intervals,
The amount of weight applied in skin traction must not exceed the tolerance of the skin.
The condition of the skin must be inspected frequently.
Cover exposed sharp ends of skeletal pins with cork or other pin covering to protect patient and
caregivers from injury.
84
Nursing Interventions
Minimizing the Effects of Immobility
1. Encourage active exercise of uninvolved muscles and joints to maintain strength and function.
Dorsiflex feet hourly to avoid development of footdrop and aid in venous return.
2. Encourage deep breathing hourly to facilitate expansion of lungs and movement of respiratory
secretions.
3. Auscultate lung fields at least twice per day.
4. Encourage fluid intake of 2,000 to 2,500 mL daily.
5. Provide balanced high-fiber diet rich in protein; avoid excessive calcium intake.
6. Establish bowel routine through use of diet and stool softeners, laxatives, and enemas, as
prescribed.
7. Prevent pressure on the calf and evaluate twice daily for the development of thrombophlebitis.
8. Check traction apparatus at repeated intervals—the traction must be continuous to be
effective, unless prescribed as intermittent, as with pelvic traction.
10. Administer prophylactic anticoagulants, as prescribed.
Maintaining Skin Integrity
1. Examine bony prominences frequently for evidence of pressure or friction irritation.
2. Observe for skin irritation around the traction bandage.
3. Observe for pressure at traction–skin contact points.
4. tell patient to Report complaint of burning sensation under traction
5. Relieve pressure without disrupting traction effectiveness by Making sure that linens and
clothing are wrinkle-free
6. Special care must be given to the back every 2 hours because the patient maintains a supine
position by having patient use trapeze to pull self up and relieve back pressure,Provide backrubs.
Avoiding Infection at Pin Site
1. Monitor vital signs for fever or tachycardia.
2. observe for signs of infection, especially around the pin tract ie. The pin should be immobile
in the bone and the skin surrounding the wound should be dry. Small amount of serous oozing
from pin site may occur,If infection is suspected, percuss gently over the tibia and this may cause
pain if infection is developing,Assess for other signs of infection warmth, redness, fever.
3. clean the pin tract with sterile gauze or applicators and prescribed solution or ointment (ie,
normal saline, sterile water, chlorhexidine) to clear drainage at the entrance of tract and
around the pin because plugging at this site can be exposed to bacterial invasion of the tract and
bone.
Preventing Neurovascular Injury
1. Assess motor and sensory function of specific nerves that might be compromised such as the
Peroneal nerve by having patient point great toe toward nose, check sensation on dorsum of foot
to determine the presence of footdrop.
2. observe for adequate circulation (eg, color, temperature, motion, capillary refill of peripheral
fingers or toes)
3. Report promptly if change in neurovascular status is identified.
Patient Education and Health Maintenance
1. Teach the patient the purpose of traction therapy.
2. Delineate limitations of activity necessary to maintain effective traction.
3. Teach use of patient aids (eg, trapeze).
4. Instruct the patient not to adjust traction apparatus.
85
5. Instruct the patient in activities designed to minimize effects of immobility on body systems.
6. Teach the patient necessity for reporting changes in sensations,pain, movement.
SPLINT
Splints are for minor fractures and for newly broken bones.
When there is swelling, splints are preferred than casts because cast can get too tight and can
affect circulation.Splint on a broken bone are usually replace with a cast after swelling reduction.
APPLYING A SPLINT
Splinting is the process of applying a rigid device to a limb, joint or wound to prevent movement
during injury
Splint are usually made from rigid materials and are used primarily for immobilization of broken
bones or dislocated joints and allow complete rest of the injured part in an anatomically correct
position
A properly applied splint helps control blood loss and pain, as fractures with sharp ends when
not splinted can cause further tissue trauma, blood loss and pain.
For comfort and to avoid further trauma padding is recommended before splinting and is held in
place with bandages or tape
Items needed on a trolley
Gloves
Dressing pack for wound, if present
Padding (gauze or cotton wool)
Splint
Elastic bandage or tape to hold splint in place
Procedure
Wash hands to reduce the transmission of micro organisms
Assess the need for a dressing if there is an open wound
Send prepared trolley to patient bedside
Assess injured site and see what kind of splint to use since this may vary according to the area to
be splinted and the type of injury
N.B some splints are made for the right side and others for the left side
Apply the splint over the area to be immobilized, securing it with an elastic bandage or tape
Check the circulatory and neurovascular status of the area distal to where the splint has been
applied
Thank patient
Discard trolley and wash hands
Some types of splints and their indications
Type of splint
Volar splint
Thumb spice splint
Radial gutter splint
Ulnar gutter splint
Anteroposterior splint
Posterior short leg
Indication
Soft tissue injury
Immobilization of the thumb
Immobilization of the 2nd or 3rd finger
Immobilization of the 3rd or 4th finger
Fracture of the distal forearm
Ankle injuries
CAST
86
A cast is an immobilizing device made up of layers of plaster or fiberglass bandages molded to
the body part that it encases.
Purposes
1. To immobilize and hold bone fragments in reduction.
2. To apply uniform compression of soft tissues.
3. To permit early mobilization.
4. To correct and prevent deformities.
5. To support and stabilize weak joints.
Types of Casts
1. Short-arm cast—extends from below the elbow to the proximal palmar crease.
2. Gauntlet cast—extends from below the elbow to the proximal palmar crease, including the
thumb (thumb spica).
Long-arm cast—extends from upper level of axillary fold to proximal palmar crease; elbow
usually immobilized at right angle.
4. Short-leg cast—extends from below knee to base of toes.
5. Long-leg cast—extends from upper thigh to the base of toes; foot is at right angle in a neutral
position.
6. Body cast—encircles the trunk stabilizing the spine.
7. Spica cast—incorporates the trunk and extremity.
a. Shoulder spica cast—a body jacket that encloses trunk, shoulder, and elbow.
b. Hip-spica cast—encloses trunk and a lower extremity.
i. Single hip-spica—extends from nipple line to include pelvis and extends to include pelvis and
one thigh.
ii. Double hip-spica—extends from nipple line or upper abdomen to include pelvis and extends
to include
both thighs and lower legs.
iii. One-and-a-half hip-spica—extends from upper abdomen, includes one entire leg and extends
to the knee of the other.
8. Cast-brace—external support about a fracture that is constructed with hinges to permit early
motion of joints, early mobilization, and independence.
a. Cast bracing is based on the concept that some weightbearing is physiologic and will promote
the formation of bone and contain fluid within a tight compartment that compresses soft tissues,
providing a distribution of forces across the fracture site.
b. Cast-brace is applied after initial edema and pain have subsided and there is evidence of
fracture stability.
9. Cylinder cast—Can be used for upper or lower extremity. Used for fracture or dislocation of
knee (lower extremity) or elbow dislocation (upper extremity).
Complications Associated with Casts
1. Pressure of cast on neurovascular and bony structures causes necrosis, pressure sores, and
nerve palsies
2. Compartment syndrome is a condition resulting from increased progressive pressure within a
confined space, thus compromising the circulation and the function of tissues within that space.
This
is a medical emergency and can be limb-threatening. A tight cast, trauma, fracture, prolonged
compression of an extremity, bleeding, and edema put patients at risk for compartment
syndrome.
87
3. Immobility and confinement in a cast, particularly a body cast, can result in multisystem
problems such as a. Nausea, vomiting, and abdominal distention associated with cast syndrome
as a result of diminished blood flow to the bowel
b. Thrombophlebitis and possible pulmonary emboli associated with immobility and ineffective
circulation (eg, venous stasis).
c. Urinary tract infection—renal and bladder calculi associated with urinary stasis, low fluid
intake, and calcium excretion associated with immobility.
Nursing Assessment
1. Assess neurovascular status of the extremity with a cast for signs of compromise.
a. Pain (pain out of proportion to injury is an indication for compartment syndrome).
b. Swelling.
c. Discoloration—pale or blue.
d. Cool skin distal to injury.
e. Tingling or numbness (paresthesia).
f. Pain on passive extension (muscle stretch).
g. Slow capillary refill; diminished or absent pulse.
h. Paralysis.
2. Assess skin integrity of casted extremity. look for:
a. Severe initial pain over bony prominences; this is a warning symptom of an impending
pressure ulcer. Pain increases when ulceration occurs.
b. Odor.
c. Drainage on cast.
3. Carefully assess for positioning and potential pressure sites of the casted extremity
a. Lower extremity—heel, malleoli, dorsum of foot, head of fibula, anterior surface of patella.
b. Upper extremity—medial epicondyle of humerus, ulnar styloid.
c. Plaster jackets or body spica casts—sacrum, anterior and superior iliac spines, vertebral
borders of scapulae.
4. Assess cardiovascular, respiratory, and GI systems for possible complications of immobility.
Maintaining Adequate Tissue Perfusion
1. Elevate the extremity on cloth-covered pillow above the level of the heart. Keep the heel off
the mattress.
2. Avoid resting cast on hard surfaces or sharp edges that can cause denting or flattening of the
cast and consequent pressure sores.
3. Handle moist cast with palms of hands.
4. Turn patient every 2 hours while cast dries.
5. Instruct patient not to place objects into cast. Advise patient of alternative methods of
managing itching such as blowing cool air under the cast.
6. Assess neurovascular status hourly during the first 24 hours, then less frequently as condition
warrants and swelling resolves.
7. If symptoms of neurovascular compromise occur:
a. Notify health care provider immediately.
b. Bivalve the cast—split cast on each side over its full length into two halves.
c. Cut the underlying padding—blood-soaked padding may shrink and cause constriction of
circulation.
d. Spread cast sufficiently to relieve constriction.
88
8. If symptoms of pressure area occur, cast may be “windowed” (hole cut in it) so the skin at the
pain point can be examined and treated.
9. Provide and encourage diversional activities.
11. Pay special attention to positioning and turning for patients in spica or body cast
Minimizing the Effects of Immobility
1. Encourage the patient to move about as normally as possible.
2. Encourage compliance with prescribed exercises to avoid muscle atrophy and loss of strength.
a. Active ROM for every joint that is not immobilized at regular and frequent intervals.
b. Isometric exercises for the muscles of the casted extremity.
Instruct patient to alternately contract and relax muscles
without moving affected part.
3. Reposition and turn patient frequently.
4. Avoid pressure behind knees, which reduces venous return and predisposes to
thromboembolism.
5. Use anti-embolism stockings and sequential compression devices (SCDs), as indicated.
6. Administer prophylactic anticoagulants, as prescribed.
Preventing Gastrointestinal Impairment
1. Encourage balanced nutritional intake.
a. Assess the patient’s food preferences. Serve small meals.
b. Provide natural bowel stimulants (eg, fiber) and good fluid intake.
c. Monitor bowel movements, bowel sounds, and use a bowel
program, if necessary.
2. Observe for symptoms of cast syndrome—nausea, vomiting, abdominal distention, abdominal
pain, and decreased bowel sounds.
3. If symptoms of cast syndrome develop, report immediately to the health care provider.
a. Place patient in a prone position, if tolerated, to relieve pressure symptoms.
b. Use nasogastric suction as prescribed.
c. Maintain electrolyte balance by intravenous (IV) replacement of fluids, as prescribed.
d. Prepare the patient for removal of the cast or surgical relief of duodenal obstruction, if
necessary.
Patient Education
Neurovascular Status
1. Instruct patient to check neurovascular status and to control swelling.
a. Watch for signs and symptoms of circulatory disturbance, including blueness or paleness of
fingernails or toenails accompanied by pain and tightness, numbness, cold or
tingling sensation.
b. Elevate affected extremity and wiggle fingers or toes.
c. Apply ice bags, as prescribed (one third to one half full), to each side of the cast, making sure
they do not make indentations in plaster.
d. Call health care provider promptly if excessive swelling, paresthesia, persistent pain, pain on
passive stretch, or paralysis occurs.
2. Instruct patient to alternate ambulation with periods of elevation to the cast when seated.
Encourage the patient to lie down several times daily with cast elevated.
Skin Irritation
Advise patient to prevent skin irritation at cast edge by padding edges of cast with moleskin cast
edges with strips of adhesive tape.
89
Exercise
1. Instruct patient to actively exercise every joint that is not immobilized and to perform
isometric exercises (contract muscles without moving joint) of those immobilized to maintain
muscle strength and to prevent atrophy.
2. Tell patient to perform hourly when awake:
a. Leg cast—push down on the popliteal space, hold it, relax,repeat. Move toes back and forth;
bend toes down, then pull them back.
b. Arm cast—make a fist, hold it, relax, repeat. Move shoulders.
3. Encourage ambulation with weight-bearing restrictions.
Cast Care
1. Advise to avoid getting cast wet, especially padding under cast—causes skin breakdown as
plaster cast becomes soft.
2. Warn against covering a leg cast with plastic or rubber boots because this causes condensation
and wetting of the cast.
3. Instruct to avoid weight-bearing or stress on plaster cast for 24 hours.
4. Instruct to report to health care provider if the cast cracks or
breaks; instruct the patient not to try to fix it.
5. Teach how to clean the cast:
a. Remove surface soil with slightly damp cloth.
b. Rub soiled areas with powder
c. Wipe off residual moisture
6.To prevent falls, avoid walking on wet floors or sidewalks. To prevent pressure and injury to
the skin, do not place objects inside the cast.
After Cast Removal
1. Instruct to clean skin with mild soap and water, blot dry, and apply emollient lotion to dry
skin.
2. Warn against scratching the skin.
3. Advise to continue prescribed exercises. Gradually resume activities and elevate extremity to
control swelling.
CHAPTER EIGHT
NURSING CARE OF PATIENTS WITH ENDOCRINE PROBLEMS
RESTING ENERGY EXPENDITURE/BASAL METABOLIC RATE
Is the amount of energy used for basic function e.g. breathing,circulation,thermoregulation etc. OR
Is the rate at which energy is used by an organism at complete rest. It forms the largest component of
energy requirement i.e. 45-70% of total energy expenditure.
OR
Is the amount of energy expended daily by humans and other animals at rest. The release and using of
energy in this state is sufficient only for the functioning of the vital organs, the heart, lungs, nervous
system, kidneys, liver, intestine, sex organs, muscles and skin
DESCRIPTION
The body’s generation of heat is known as thermogenesis and it can be measured to determine the amount
of energy expended.BMR generally decrease with age and with the decrease in lean body mass (as may
happen with aging) increasing muscle mass increases BMR,although the effect is not significant enough
to act as a weight loss method
90
BMR is measured under restrictive circumstances when a person is awake.an accurate BMR measurement
requires complete rest of the person
FACTORS AFFECTING BMR
Age
Sex
Diet
Pregnancy
PREPARATIONOF A PATIENT FOR BMR
Explain procedure to patient.
Ask patient to empty bladder and bowel
Check vital signs especially weight, height, RBS.
BMR ESTIMATION FORMULAE
Harris-benedict equation
For men,
P =[m(kg) +h (cm) –a (yrs) + 88.4] kcal/d
For women,
P =[m(kg) + h (cm) –a (yrs) + 447.6] kcal/d
Where p is total heat production at complete rest, m is the weight, h is the height, and a is the age
It was the best prediction equation until 1990, when Mifflin et al introduced the equation
The Mifflin St Jeor equation:
P = [m(kg) + h (cm) – a(yrs) + s] kcal/day
Where s is +5 for males and -161 for females
These formulas are based on body weight, which does not take into account the difference in
metabolic activity between lean body mass and body fat
The schofield equation:
CALCULATION OF BMR USING SCHOFIELD EQUATION (Weight in Kg)
AGE
MALES (Kcal/day)
FEMALES (Kcal/day)
10-17
17.7Wt +657
13.4Wt +692
18-29
15.1Wt +692
14.8Wt +487
30-59
11.5Wt +873
8.3Wt +846
91
60-69
11.9Wt + 700
9.2Wt +687
70+
8.4Wt + 821
9.8Wt +624
EAMPLE
Mrs.Ansu is 53yrs old woman has weight of 65Kg and height of 165cm.Calculate her BMR
using schofield equation.
Maintaining a healthy body mass index
The body mass index is a way of statistically measuring the amount of fat in a person’s body
based on their height and weight
BMI is a relatively easy and cheap way for men and women to be able to assess their weight
within a given range-ranges vary depending on a person’s weight and height
It needs to be remembered that body mass alone is not necessarily an indication of how healthy
an individual may or may not be and each height and weight group has its own range
RANGES OF BMI
Less than 18.5, it is considered as underweight
Between 18.5-25 it is considered to be good body weight
Between 25-30, it is to be overweight
Between 30-40, it is considered to be obese
Above 40 it is considered to be very obese
THE BODY MASS INDEX CALCULATION
BMI is defined as the weight in kilograms divided by the square of the height in meters (kg/m2)
As such the body mass index calculation uses the following equation:
BMI= weight/ (height) 2
Example of calculating BMI
If a person weighs 85kg and is 1.75 meters tall, the person’s body mass calculation is as follows
BMI = 85/ (1.75)2 = 27.8
HOW TO MAINTAIN A NORMAL BMI
a. Monitor your eating habits
b. Try to eat slowly so that you get time to chew food properly.
c. You should be relaxed while eating food. If you are stressed, it can affect the
process of digestion
d. You should avoid overeating
e. Never skip breakfast
f. You should eat healthy and small meals through the day
92
g.
h.
i.
j.
k.
Eat plenty of fruits and vegetables
Avoid processed foods such as white bread, cake, cookies, rolls and pastries
Avoid fatty, fried foods and limit your consumption of oil, butter and margarine
Exercise on a regular basis
Find time to perform some physical activity at least 4 to 5 times every week. Go
for a walk or jog regular exercise helps burn fat and improve muscle structure and
strength
l. Manage your weight
m. Check your weight on a weekly basis. If you see an increase in your weight, try to
figure out the cause. If you see an increase of more than 5Ibs, increase your level
of activity and reduce your food intake until your weight is back to where it was.
CHAPTER NINE
NURSING CARE OF PATIENTS WITH NEUROLOGICAL PROBLEMS
COMPUTERIZED TOMOGRAPHY SCAN
Is a painless, non-invasive x-ray procedure that has the unique capability of distinguishing minor
differences in the density of tissues. It produces a three-dimensional image of the organ making
it more sensitive than the x-ray.
The table will move quickly through the scanner to determine the correct starting position for the
scans. Then, the table will move slowly through the machine as the actual CT scanning is
performed.
The CT scanning is usually completed within 30 minutes.
Most CT exams are painless, fast and easy.
Though the scanning itself causes no pain, there may be some discomfort from having to remain
still for several minutes.
If an intravenous contrast material is used, a warm, flushed sensation may be felt during the
injection of the contrast materials and a metallic taste in the mouth that lasts for a few minutes.
Occasionally, patients develop hives and an itch, which can be relieved with medication, become
light-headed or experience difficulty breathing indicate a more severe allergic reaction.
Preparing for the CT Scan
 Explain the procedure to the patient/family
 Reassure patient and allow him to ask question to allay their fears
 Encourage client to wear comfortable, loose-fitting clothing/gown for the test.
 Remove all metal objects including jewellery, eyeglasses, dentures and hairpins. These
may affect the CT images and should be left at home or removed prior to the test as well
as hearing aids and removable dental work.
 Ask patient not to eat or drink anything for several hours before the scan, especially if a
contrast material will be used.
 Assess patient for any recent illnesses or medical conditions, and a history of heart
disease, asthma, diabetes, kidney disease or thyroid problems. Any of these conditions
may increase the risk of an unusual adverse effect.
 Assess female patients for pregnancy.
 Introduce patient to the equipments and explain the uses and what is expected of him.
Also, many CT exams require the patient to hold their breath several times. This helps to
93
eliminate blurring from the images, which can be caused by breathing or other patient
motion.
Benefits
• Offers an accurate evaluation of bone and most soft tissues.
•CT scanning is painless, non-invasive and accurate.
•Provides detailed images of bone, lungs and other soft tissue and blood vessels all at the same
time.
•CT examinations are fast and simple; in emergency cases, they can reveal internal injuries and
bleeding quickly that helps save lives.
•It is less sensitive to patient movement.
•CT can be performed if you have an implanted medical device of any kind, unlike MRI.
•CT provides real-time imaging, making it a good tool for guiding minimally invasive
procedures such as needle biopsies and needle aspirations of many areas of the body, particularly
the lungs, abdomen, pelvis and bones.
•
No radiation remains in a patient's body after a CT examination.
•
X-rays used in CT scans usually have no side effects.
Risks
•
CT scanning is, in general, not recommended for pregnant women because of potential
risk to the baby.
•
Nursing mothers should wait for 48 hours after contrast material injection before breastfeeding.
•
The risk of serious allergic reaction to contrast materials that contain iodine is rare
•
Children should have a CT study only if it is essential for making a diagnosis and should
not have repeated CT studies unless absolutely necessary.
ELECTRO ENCEPHALOGRAPHY
Electroencephalography (EEG) is an electrophysiological monitoring method to record electrical
activity of the brain. It is typically noninvasive, with the electrodes placed along the scalp,
although invasive electrodes are sometimes used in specific applications. EEG measures voltage
fluctuations resulting from ionic current within the neurons of the brain. In clinical contexts,
EEG refers to the recording of the brain's spontaneous electrical activity over a period of time, as
recorded from multiple electrodes placed on the scalp.
An EEG is a test used to evaluate the electrical activity in the brain.
Small, flat metal discs called electrodes are attached to the scalp with wires. The electrodes
analyze the electrical impulses in the brain and send signals to a computer, where the results are
recorded.
The electrical impulses in an EEG recording look like wavy lines with peaks and valleys. These
lines allow doctors to quickly assess whether there are abnormal patterns. Any irregularities may
be a sign of seizures or other brain disorders. It usually takes 30 to 60 minutes to complete.
94
INDICATIONS
I.
II.
III.
-
An EEG is used to detect problems in the electrical activity of the brain that may be
associated with certain brain disorders including;seizure disorders (such as epilepsy),a
head injury,encephalitis (an inflammation of the brain),a brain tumor,encephalopathy
(a disease that causes brain dysfunction) ,memory problems,sleep
disorders,stroke,dementia
When someone is in a coma, an EEG may be performed to determine the level of
brain activity.
The test can also be used to monitor activity during brain surgery
PREPARATION
Describe and explain the procedure to the patient/family and tell them who will perform
the test
Tell patient he will be asked to lie on a bed and electrodes will be attached to his head
Continue to reassure patient and allow him to ask questions to allay his fears
As ordered, withhold anticonvulsants, tranquilizers, barbiturates and other sedatives for
24-48 hours before the test.
Wash or instruct patient to wash his/her hair the night before the EEG, and do not put
any products (such as sprays or gels) in the hair on the day of the test.
Tell patient not to take any food or drinks especially those containing caffeine for at least
eight hours prior to the test.
Reinforce doctor’s instructions by asking the patient to sleep as little as possible the
night before the test if patient is required to sleep during the EEG.
Tell patient he can continue with his routine activities for the day after EEG.
During the test, very little electricity is passed between the electrodes and the skin, so tell
the patient he may feel very little to no discomfort.
A routine clinical EEG recording typically lasts 20–30 minutes (plus preparation time)
and usually involves recording from scalp electrodes.
Assure patient that the electrodes will not cause shock, and encourage patient to relax
during the procedure because anxiety can affect brain wave patterns.
Meals should be taken as usual to avoid sudden changes in blood glucose levels.
Send patient to the unit on time to help him relax before the test
AFTER CARE
Review with doctor the reinstatement of all withheld drugs before the test
Return patient to the ward and make him comfortable in bed
Observe patient for signs of seizures and record
Help patient remove electrodes from his hair.
MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging (MRI) is a technique that uses a magnetic field and radio waves to
create detailed images of the organs and tissues within the body. Other names are: Magnetic
resonance imaging; Nuclear magnetic resonance (NMR) imaging. Most MRI machines are large,
tube-shaped magnets. When a client lies inside an MRI machine, the magnetic field temporarily
realigns hydrogen atoms in his body. Radio waves cause these aligned atoms to produce very
95
faint signals, which are used to create cross-sectional MRI images like slices in a loaf of
bread.MRI is a noninvasive way for examining the organs, tissues and skeletal system. It
produces high-resolution images that help diagnose a variety of problems.MRI is the most
frequently used imaging test of the brain and spinal cord. The most common type of contrast
(dye) used is gadolinium. It is very safe. Small devices, called coils, may be placed around the
head, arm, or leg, or around other areas to be studied. These help send and receive the radio
waves, and improve the quality of the images
INDICATIONS

















Aneurysms
Disorders of the eye and inner ear
Multiple sclerosis
Spinal cord injuries
Stroke
Tumors
The size and function of the heart's chambers
Thickness and movement of the walls of the heart
The extent of damage caused by heart attack or heart disease
Structural problems in the aorta, such as aneurysms or dissections
Inflammation or blockages in the blood vessels
Joint disorders, such as arthritis
Joint abnormalities caused by traumatic or repetitive injuries
Disk abnormalities in the spine
Bone infections
Tumors of the bones and soft tissues
MRI may be used in addition to mammography to detect breast cancer, particularly in
women who have dense breast tissue or who may be at high risk of the disease.
PREPARATION
-Assess the client for the presence of any metal or electronic devices in the body, such
as:Metallic joint prostheses,Artificial heart valves,An implantable heart defibrillator,A
pacemaker,Metal clips,Cochlear implants,any other type of metal fragment
-Assess female patients for pregnancy, kidney or liver problems because problems with these
organs may limit the use of injected contrast agents during the scan.
-Ask client not to eat or drink anything for 4 to 6 hours before the scan unless otherwise
instructed.
-Ask client to change into a gown and to remove: (Jewelry, Hairpins, Eyeglasses, Watches,
Wigs, Dentures, Hearing aids)
-If possible, introduce the client to the MRI equipment and explain the function as well as what
the client is expected to do during the procedure
-Explain to client that in some cases, a contrast material, typically gadolinium, may be injected
through an intravenous (IV) line into a vein which enhances the appearance of certain details.
-The material used for MRIs is less likely to cause an allergic reaction than the material used for
CT scans.
96
-Tell client that MRI can last up to an hour or more and that he must hold very still because
movement can blur the resulting images.
Advantages of MRI
No ionizing radiation, sensitivity to blood flow, imaging in several planes, and superior
visualization of
soft tissues. An important advantage is its ability to distinguish water, iron, fat, and blood.
Sensitive to detection of white matter changes and valuable in detecting changes associated with
Alzheimer’s disease and multiple sclerosis.
Disadvantages of MRI
Contraindicated for patients with pacemakers, nontitanium aneurysm clips, or other implanted
objects that could be dislodged by the magnetic field. Dental amalgam, gold, and stainless steel
are generally
considered safe, but may distort the image. If contrast is used, there is the risk of contrastinduced nephropathy. MRI scanner has the appearance of a tunnel-like chamber, and its
constricted opening prevents its use for extremely obese people. Because of its narrow
dimensions, MRI may induce claustrophobic and anxiety reactions, so anti-anxiety medication
may be necessary before the procedure or an open MRI may be used.
Nursing Care
1. Encourage patient to use the bathroom before the procedure because it may take from 20 to 60
minutes, though the scan time is dependent on the protocol requested and number of scans
performed.
2. Instruct patient to remove metal items, including eyeglasses, jewelry, hair clips, hearing aids,
dentures, and clothing with zippers, buckles, or metal buttons.
3. Evaluate for adequate renal function if contrast will be used
4. Encourage patient to remain as still as possible during the procedure.
5. Describe the tunnel-like narrow chamber of the closed MRI scanner and inform patient it
sometimes causes feelings of anxiety or claustrophobia. Evaluate the need for sedation.
6. Inform patient the scanner will make a dull, thumping noise throughout the procedure.
7. Tell patient to resume usual activities after the procedure.
CRANIAL NERVES ASSESSMENT
Assessment of the Cranial Nerves provides an insightful and vital information about the patient’s
nervous system. There are 12 cranial nerves which are often forgotten by nurses, the table below
will help you in the assessment of your patient’s nerve responses.
Cranial Nerves Assessment Form
Cranial Nerve
I. Olfactory
Assessment
Technique
Normal Response
Client’s Response
Client was able to
Ask the client to smell Client is able to
and identify the smell identify different smell describe the odor of the
materials used.
of cologne with each with each nostril
97
nostril separately and
with the eyes closed.
II. Optic
III. Oculomotor
separately and with
eyes closed unless such
condition like colds is
present.
Provide adequate
lighting and ask client
The client should be
Client was able to read
to read from a reading
able to read with each with each eye and both
material held at a
eye and both eyes.
eyes.
distance of 36 cm. (14
in.).
Reaction to light:
Using a penlight and
approaching from the
side, shine a light on
the pupil. Observe the Illuminated and nonresponse of the
illuminated pupil
illuminated pupil.
should constrict.
Shine the light on the
pupil again, and
observe the response of
the other pupil.
Reaction to
accommodation: Ask
Pupils constrict when
client to look at a near
looking at a near
object and then at a
object, dilate when
distant object.
looking at a distant
Alternate the gaze
object, converge when
from the near to the far
near object is moved
object. Next, move an
towards the nose.
object towards the
client’s nose.
IV. Trochlear
PERRLA (pupils
equally round and
reactive to light and
accommodation)
Hold a penlight 1 ft. in
front of the client’s
Client’s eyes should be
Both eyes are able to
eyes. Ask the client to able to follow the
follow the movements penlight as it moves. move as necessary.
of the penlight with the
eyes only. Move the
98
penlight upward,
downward, sideward
and diagonally.
While client looks
upward, lightly touch
lateral sclera of eye to
elicit blink reflex.
V. Trigeminal
To test light sensation,
have client close eyes, Client should have a
Client was able to elicit
wipe a wisp of cotton (+) corneal reflex, able
corneal reflex,
over client’s forehead. to respond to light and
sensitive to pain
deep sensation and able
stimuli and distinguish
To test deep sensation, to differentiate hot
hot from cold.
use alternating blunt
from cold.
and sharp ends of an
object. Determine
sensation to warm and
cold object by asking
client to identify
warmth and coldness.
VI. Abducens
Hold a penlight 1 ft. in
front of the client’s
eyes. Ask the client to
follow the movements Both eyes coordinated,
Both eyes move in
of the penlight with the move in unison with
coordination.
eyes only. Move the
parallel alignment.
penlight through the
six cardinal fields of
gaze.
VII. Facial
Ask client to smile,
raise the eyebrows,
frown, and puff out
cheeks, close eyes
tightly. Ask client to
identify various tastes
Client should be able Client performed
various facial
to smile, raise
eyebrows, and puff out expressions without
cheeks and close eyes any difficulty and able
without any difficulty. to distinguish varied
The client should also tastes.
99
placed on tip and sides be able to distinguish
of tongue.
different tastes.
VIII.
Vestibulocochlear
Have the client occlude
one ear. Out of the
client’s sight, place a Client should be able
Client was able to hear
tickling watch 2 to 3
to hear the tickling of
tickling in both ears.
cm. ask what the client the watch in both ears.
can hear and repeat
with the other ear.
Ask the client to walk
across the room and
back and assess the
client’s gait.
Ask the client to say
“ah” and have the
patient yawn to
observe upward
movement of the soft
IX. Glossopharyngeal palate.
Elicit gag response.
The client was able to
The client should have
stand and walk in an
upright posture and
upright position and
steady gait and able to
able to maintain
maintain balance.
balance.
Client should be able
to elicit gag reflex and
swallow without any
difficulty.
Client was able to elicit
gag reflex and able to
swallow without
difficulty.
The client should be
able to swallow
without difficulty and
speak audibly.
Client was able to
swallow without
difficulty and speak
audibly.
Note ability to
swallow.
X. Vagus
Ask the patient to
swallow and speak
(note hoarseness)
XI. Accessory
Ask client to shrug
shoulders against
Client should be able
resistance from your
to shrug shoulders and
hands and turn head to
turn head from side to
side against resistance
side.
from your hand (repeat
for other side).
100
Client was able to
shrug his shoulders and
turn his head from one
side to the other.
XII. Hypoglossal
Ask client to protrude
The client should be
The client was able to
tongue at midline and
able to move tongue
move tongue in
then move it side to
without any difficulty. different directions.
side.
NEUROLOGIC EXAMINATION
It is an examination performed by the doctor to test for nerve reflexes and sensory perception of
the patient suspected to be suffering from a disease or injury of the centralnervous system
e.g.Apoplexy.
OR
Is a systematic examination hat surveys the functioning of the nerves delivering sensory
information to the brain to determine whether the nervous system is impaired or not.
It can be used both as a screening tool (when there is no expected neurological deficit) and an
investigative tool (when you expect to find abnormalities)
Indication of neurological exams iswhen a patient is suspected to have a neurological disorder
Neurological examination is focused on finding out if there are lesion in the central and
peripheral nervous system
Neurological examination
Patient’s history is the most important part of neurological examination and must be perform
before any other procedure.
History include:
Time of onset of complaint and duration(acute or chronic)
Age,gender and occupation of patient
Past medical history
Drug history
Family and social history
Neurological examination assesses motor and sensory skills the functioning of one or more
cranial nerves,hearing and speech, vision, coordination and balance, mental status and
changes in mood or behaviour among other abilities
PREPARATION OF PATIENT FOR NEUROLOGICAL EXAMINATION
1.
2.
3.
4.
5.
6.
7.
8.
Introduce yourself and inform patient about who will carry out the procedure
Verify the identity of the client
Explain procedure to the patient
Provide privacy
Put client in a comfortable position
Send prepared trolley to client’s bedside
Assist doctor during the procedure
Thank patient after the procedure
101
9. Discard trolley
10. Document procedure and findings in the nurse’s notes
Items for neurological exam include:
A trolley containing
11. Ophthalmoscope
12. Touch light to test for the eye (pupil dilatation).
13. Auroscope to visualize the internal organs of the ears to detect any discharge.
14. Turning fork for hearing.
15. Tongue depressor to control the tongue.
16. Percussion hammer or patella/reflex hammer — for knee reflexes(normal patient
will jerk)
17. Test for taste sugar or vinegar or salt on trolley.
18. To test for smell — a perfume on trolley.
19. To test for touch — a coin or cotton wool balls or a pin.
20. Cold and hot water for skin temperature assessment
21. Needles
22. Tape measure
23. B.P apparatus
24. Neurologic chart
LUMBAR PUNCTURE/SPINAL TAP
Is insertion of a needle into the lumbar subarachnoid space, usually between the third and fourth
lumbar vertebrae, and CSF is withdrawn for diagnostic and therapeutic purposes.
CSF is normally a crystal clear, colourless and sterile liquid which resembles water.
CSF pressure can be measured but is contraindicated in patients where raised intracranial
pressure is suspected.
A red discolouration — presence of blood.
Cloudy — presence of a large number of white cells and protein.
Turbidity — causes of turbidity include infection, leukemia, lymphoma
Indications
1. helps in the diagnosis of viral or bacterial meningitis, subarachnoid or intracranial
hemorrhage, tumors, and brain abscesses.
2.Administering antibiotics and cancer chemotherapy intrathecally in certain cases
3. Measuring cerebrospinal pressure and assisting in detection of obstruction of CSF circulation
4. To treat increase intracranial pressure by removing excess CSF
5. Introduction of spinal anaesthesia for surgery.
6. Introduction of radiopaque pictures (myelograms) of the spinal cord.Myelograms are used in
diagnosing spinal lesions and helping to plan surgery by isolating the level of lesions.
7. May be used to assist in the diagnosis of Alzheimer’s disease.
CONTRAINDICATIONS
Bleeding disorders
Skin infection at the punctured site
102
Abnormal respiratory pattern
Hypertension with bradycardia or deteriorating consciousness
Vertebral deformities(scoliosis or kyphosis)
Requirements
Antiseptic skin cleaning agents —methylated spirit,Needles/syringes.,Local anaestheticlidocaine
1%,Sterile gloves,Lumbar puncture needles of assorted size,Sterile dressing pack,Disposable
manometer,Three sterile specimen bottles( should be labeled 1, 2, and 3),Plaster
dressing,Protective mackintosh.
NURSES’ RESPONSIBILITIES
Before
1. Explain the procedure to patient.
2.Tell the patient to empty bladder and bowel.
3.For lying,position the patient on side with a small pillow under head and a pillow between
legs. Patient should be lying on a firm surface
Assist the patient to arch the lumbar segment of back and draw knees up to abdomen, chin to
chest, clasping knees with hands
Assist the patient in maintaining this position throughout the procedure by supporting behind the
knees and upper back and neck.
4. For sitting position, have the patient straddle a straight-back chair (facing the back) and rest
head against arms, which are folded on the back of the chair.
5. Provide screen.
During procedure
1. Continue to support, encourage and observe the patient throughout the procedure.
2. Assist doctor as required.
(a) Doctor will proceed to clean the skin with antiseptic agents.
(b) Identify the area to be punctured and anaesthetize with lidocaine.
(c) Introduce a spinal puncture needle between the third and fourth lumbar interspace and into
the subarachnoid space.
(d) Ensure that the subarachnoid space has been entered and attach the manometer to the spinal
needle if required. After the needle enters the subarachnoid space, help the patient to straighten
up slowly to prevents a false increase in intraspinal pressure
Tellt the patient to breathe quietly (not to hold breath or strain) and not to talk because
hyperventilation may lower a truly elevated pressure and talking can elevate CSF pressure
(e) Obtain about 2−3 mL of spinal fluid and place them in each of the 3 test tubes for
observation, comparison, and laboratory analysis. Spinal fluid should be clear and colorless
(f) Withdraw the spinal needle once specimens have been obtained, appropriate pressure
measurements taken and intrathecal medications administered if required.
After procedure
1. When the needle is withdrawn, apply pressure over the lumbar puncture site using a sterile
swab
2. Tell the patient is instructed to remain flat for about 2 hours.
3. Ensure adequate hydration with oral or parenteral fluids.
4. Observe the patient for the next 24 hours for leakage from the puncture site. headache,
backache, neurological observations and vital signs.
5. Remove equipment and dispose of as appropriate.
6. Record the procedure in the appropriate documents.
103
7. Ensure the specimen are labeled appropriately and sent with correct for laboratory.
COMPLICATIONS
a. Infection
b. Haemorrhage
Tonsillar herniation
c. Headache
d. Backache
e. Leakage from puncture site
f. Arachnoiditis
CHAPTER TEN
NURSING CARE OF PATIENTS WITH ABNORMALITIES OF THE EYE
Eye irrigation
Is administered to wash out the conjunctival sac to remove secretions or foreign bodies from the
eye or remove chemicals that are capable of injuring the eye.
Indications
- To relief pain
- To treat infections
- To reduce inflammation
Requirements
Tray containing medication
Gallipot with cotton wool swabs
Procedure
1.Explain procedure to the patient
2.Examine the labeling on the medication tube or bottle with the patient chart and be sure of
when medication expires
3.Perform hand hygiene
4. Provide privacy
8. Help patient into a comfortable position, either sitting up or lying with the head thrown backwhich is more comfortable
9. Don clean gloves
10. The eye lid and eye lashes must be cleaned using a sterile cotton ball soaked with sterile
saline solution this is to prevent contamination of the other eye and the lacrimal duct
11. Instruct patient to look up to the ceiling (he is likely to blink when he looks up) with the
thumb or fingers of your non-dominant hand on the patient’s cheekbone just below the eye,
gently draw down the skin on the cheek. Hold the medication in your non dominant hand and
place your hand on the patient’s forehead to stabilize hand
12. Instill the correct number of drops onto the outer third of the lower conjunctival sac using the
side approach(he is less likely to blink if side approach is used)hold dropper 1-2 cm above
sac
13. Remove your hand and allow the lower eyelid to return to its original position to ensure the
spread of the medication over the eyeball
14. If an ointment is used hold the tube above the conjunctival sac and squeeze about 2 cm of
ointment from the tube into the conjunctival sac from the inner canthus outward
104
15. Instruct patient to close eyelid gently
16. The eyelids should be wiped gently from the inner canthus to the outer to collects excess
medication
17. Apply an eye pad if needed and secure with an eye tape
18. Appropriate documentation should be done in the nurse’s notes
19. Assess patient response after the procedure and report any anomaly to the nurse in charge
REQUIREMENTS FOR EYE EXMINATION
A clean tray containing
Torch light
Loop(magnifying lens)
Ophthalmoscope
Gallipot with swabs
Gallipot with saline solution
Disposable gloves
Slit lamp
Receiver for used swabs
Preparation of patients for eye examination
 Place patient in a well-lighted and appropriate room
 Introduce yourself to the patient and verify the patient’s identity
 Explain the procedure to the patient and relatives. Provide privacy
 Find out if the patient has any family history of diabetes, hypertension, eye diseases,
injury, last visit to the ophthalmologist, current use of medication and contact lenses
 Assemble required equipments (millimetre ruler, penlight, Snellen or E chart, opaque
card)
 Perform hand hygiene and wear gloves
 Inspect the eyebrows for hair distribution and alignment
 Inspect the eyelashes for eveness of distribution and direction of curl
 Inspect the eyelids for characteristics such as: position in relation to the cornea, ability to
blink, and frequency of blinking
 Check the bulbar conjunctiva for color and presence of lesions and clarity of the cornea
 Check the pupil for color, shape, color and reaction to accommodation
 Assess distance vision by asking the client to sit 6m (20 ft) away from a Snellen or
character chart, cover the eye not being tested and identify the letters on the chart. Take
three (3) readings each eye and then both.
 Record the reading of each eye and both eyes
 Encourage client to do follow ups
EYE CARE
105
Eye care is the practice of assessing, cleaning or irrigating the eye
INDICATIONS
Eye care is necessary under the following circumstances
1. To relieve pain and discomfort.
2. To prevent or treat infection.
3. To prevent further injury to the eye.
4. To detect disease at an early stage.
5. To detect drug toxicity at an early stage.
6. To prevent damage to the cornea.
7. To maintain contact lenses and care for false eye prostheses.
ANATOMY
The globe is divided into;
. Outer layer composed of the cornea, sclera.
. Middle layer-choroid, ciliary body and Iris.
. The inner layer or nervous Tunic is composed of the Retina.
GENERAL PRINCIPLES OF EYE CARE
1. Making use of aseptic technique.
2. Position of the patient — the patient should be in the sitting or lying with his/her head tilted
backwards and chin pointing upwards. This allows for easy access to the eye and is usually a
good position for patient comfort.
3. Position of light source - a good light source is necessary to enable careful assessment of the
eye and to avoid damage to their delicate structures.
The light source should be positioned and behind the nurse. It should never be allowed to shine
directly into the patient’s eyes, since it makes him uncomfortable.
106
INSTILLA TION OF DROPS
Most type of drops is instilled into the upper rim of the inferior fornix (le just inside the lower
eyelid). The conjunction in this area is less sensitive than that overlying cornea.
Also the drop will run into the pocket of the inferior fornix preventing immediate loss of the
drops into the nasolacrimal drainage system.
The number of drops instilled depends on the type of solutions used and its purpose.
Usually 1 to 2 drops are ordered and will be sufficient if it is instilled in the correct manner.
How to Instill Eye Drops
. The dropper should be held as close to the eye as possible without touching either the lids or the
cornea.
This will avoid cornea damage.
. The eye should be closed for as long as possible after application preferably for 1-2 minutes.
. A variety of droppers and bottles are available for the instillation of eye preparation, example
pipette.
. Each patient should have their own, individual eye drop container and single dose containers
and single dose containers should be used for all patients in eye clinics.
Equipment
Sterile dressing pack.
Sterile N/S for irrigation.
Appropriate eye drops.
Procedure
Explain procedure to patient.
Wash hands.
If there is any discharge, proceed as for eye swabbing.
Consult the patient’s treatment sheet and ascertain the following —
107
(a) Drug
(b) Dose
(c) Date and time for administration.
(d) Route and method of administration including which eye the drops are prescribed for.
(e) Expiry date on bottle.
(f) Validity of prescription.
(g) Signature of doctor.
Assist the patient into the correct position, example head well supported and tilted back.
Wash hands thoroughly using antiseptic/bactericidal soap and dry.
Place a sterile swab on the lower lid against the lid margin and gently pull dawn to evert the
lower eye lid.
Ask the patient to look up immediately before instilling the drop.
Ask the patient to close the eye. Keep the wet swab on the lower lid.
Make the patient comfortable. Remove and dispose of equipment. Wash hands.
Report and record findings.
Instillation of Eye Ointment
Ointments are also applied to the upper rim of the inferior fornix using a similar technique to eye
drops.
A 2cm line of ointment should be applied from the nasal canthus outwards.
Equipment
1. Sterile dressing pack.
2. N/S or 0.9% sodium chloride for irrigation.
3. Appropriate eye ointment.
Procedure
108
1. Explain and discuss the procedure with patient.
2. Wash hands.
3. If there is any discharge, to remove any previous application of ointment, proceed as for eye
swabbing.
4. Consult the patient treatment sheet to ascertain the following;
(a) Drug.
(b) Dose
(c) Date and time for administration.
(d) Route and method of administration including which eye the drops are prescribed for.
(e) Expiry date on bottle.
(f) Validity of prescription.
(g) Signature of doctor.
5. Wash hand thoroughly.
6. Place a wet sterile towel on the lower lid against the lid margin.
7 slightly evert the lower lid by pulling on the sterile swab. Ask patient to look up immediately
before applying the ointment.
8. Apply the ointment by gently squeezing the tube; draw a line along the inner edge of the lower
lid from the inner cornea outwards.
Ask the patient to close the eye and remove excess ointment with new sterile swabs.
10. Warn the patient that, when the eye ¡s opened, vision will be a little blurred for a few
minutes.
ii. Make the patient comfortable.
12. Remove and dispose of equipment.
13. Wash hands with bactericidal soap and water.
14. Complete the patient’s recording chart. Report and record findings.
109
ABBREVIATION IN EYE
OP or RE Right Eye
OS or LE Left Eye
OU or 02 Both Eyes
EOM Extra ocular mumcle
H-Hypermetropia
ST-(entropion) / Estropia-eyelid turns inwards
XT – (ectropion)/Extropia-eyelid turns outwards (usually in glaucoma)
Hypometropia - Myopia — short sightedness
Double vision or seeing an object as two.
Ptosis - Drooping of the upper eye lid due to paralysis of the 3 cranial nerve.
Hemianopia - partial blindness of half of the field vision.
Photophobia- Abnormal sensitivity of light and fear of light.
Presbyopia - lessening of power of accommodation due to ageing process.
Myopia - short sightedness.
Emetropia - normal vision.
Ametropia - defective vision.
Hypermetropia - long sighted ness.
EXTERNAL
This includes the reaction of the pupils to light and accommodation and ability to move the orbit.
Patient identifies numerated letters or objects with oneor both eyes, one eye open and the other
covered.
Observation of the patient is made to prevent the patient from squinting .Patient should be at a
distance of about 6m. If he reads all at this distance he is given 6/6.
110
Test for Ocular vision — this is done to identify various colours, letters, figures, which is
designed in colour parts.
REFRACTION — when a defective vision is defected by observing objects which are not
focused correctly or the retina. Atropine is used to paralyze the nerve ending.
INTERNAL EXAMINATION
The use of ophthalmoscope to view the interior part of the eye and the structural changes.
This examination helps the doctor to detect some systemic diseases like
Diabetes and Hypertension.
Tonometer is used to measure tension in the eye ball. Normal tension in the eye ball is 1122mm/Hg.
General Preparation of Patient Undergoing Eye Surgery
All patients going for eye surgery should be psychologically and physically prepared.
GENERAL PRE-OPERATIVE CARE
Psychological
-
Explain the surgery.
-
Answer questions.
-
Show pictures.
-
Show patients who have undergone same surgery successfully
Including
1. Orientate patient to his new surroundings.
2. Help him to express any fears regarding loss of vision.
3. Instruct him to wear dark glasses if atropine drops have been used.
4. Maintain safe environment for the patient.
5. Administer enema if this has been ordered.
6. Prepare the affected eye by cleaning the skin of that side of the face the night before and on
the morning of surgery.
111
7. Trim the eye lashes using blunt ended scissors covered with Vaseline or shave as required.
8. Wash and dry hands.
9. Educate the patient on post-operative restrictions specific to his surgery.
10. Inform the patient that he will be wearing an eye pad and shield on the operative eye when he
returns from surgery and that the unaffected eye may also be covered.
11. Never use adhesive in ophthalmic cases.
12. Remove any dentures and prosthesis before surgery.
13. Squeezing of the eye should be avoided during and after Surgery.
14. Take instructions from surgeon when local anaesthesia is used.
15. Teach patient to use hand bell for communication
16. A mark should be made over the face at the affected part at the forehead with colouredpencil.
CHAPTER ELEVEN
NURSING CARE OF PATIENT WITH EAR-NOSE-THROAT( E.N.T.)PROBLEMS
Assessment of the ear includes direct inspection and palpation of the external ear, inspection of
the internal ear and determination of auditory acuity. The purpose of ENT examination is to
detect any abnormalities of ear, nose and throat.
Preparation
It is important to conduct the ear and hearing examination in an area that is quiet
Find out if patient has any family history of hearing loss, presence of ear pain, medication
history.
•
Prior to performing the procedure, introduce yourself and verify the client’s identity
•
Explain the importance of the procedure to the patient and relatives
•
Wash hands and observe infection control measures
•
Provide privacy
•
Put patient in a comfortable position
PROCEDURE FOR EAR EXAMINATION
112
•
Inspect the external ear for color, symmetry of size, and position
•
Palpate the auricle for texture, elasticity, and areas of tenderness. (gently pull the auricle
upward, downward, and backward. Fold the pinna forward; it should recoil. Apply pressure to
the mastoid process)
•
Inspect the external ear canal for cerumen, skin lesions, pus and blood.
•
Visualize the tympanic membrane by an otoscope and inspect for color
•
Assess client’s response to normal voice tones. If a client has difficulty hearing the
normal voice, perform a watch tick test or a tuning fork test. The tuning fork test performs either
the Weber’s test to assess bone conduction of sound or the Rinne test to compare air conduction
to bone conduction
•
Document the findings in clients folder
•
In the case of OPD clients, encourage them to do follow-up
EQUIPMENTS FOR EAR EXAMINATION
Head light: Used to get clear vision of the ear canal
Tuning fork: To determine whether a hearing loss is conductive or perceptive.
Otoscope: to examine the auditory canal and tympanic membrane for infection or blockage due
to the presence of a foreign object or buildup of wax.
Aural speculum: A cone or funnel shaped attachment for an otoscope which is inserted into the
ear canal to examine the eardrum.
Zoellnersucker used for suction in middle ear.
Crocodile forceps to remove foreign body from ear, nose, throat (ENT) procedure.
Jobson-horneprobe used for removal of wax and cleaning of ears.
-
Assessment of the nose includes inspection and palpation of the external nose, patency of
the nasal cavities and inspection of the nasal cavities.
This can be done by the nurse with a nasal speculum and a flashlight/penlight. However
other equipments such as:
J - sucker Used for removal of crust from the nose or discharge
Thudicum nasal speculum Used for visualization of external nose.
Vienna nasal speculum used in Anterior nasal packing, Septoplasty, Removal foreign
body and rhinolith (calculus present in the nasal cavity).
113
Rigid scope: This exam allows a complete and detailed visualization of all nasal mucosa, nasal
turbinates, openings into the sinuses, and nasopharynx.
Flexible scope: to help examine places that are hard to reach.
Tilley forceps: To perform anterior nasal packing, remove foreign bodies, crusts or packs from
the nose, to pack the nose with gauze strips during nasal surgeries or sinus surgeries, to remove
cartilage and bone pieces during septoplasty
sinus forceps Used for removing or inserting dressing packs.
PROCEDURE FOR NOSE EXAMINATION
•
Inspect the external nose for any deviation in shape, size, or color and flaring or
discharges from the nose
•
Palpate for any tenderness, masses, and displacement of the bone and cartilage
•
Determine patency of both nasal cavities by exerting pressure on one naris; ask patient to
close the mouth and breath through the other naris.
•
Inspect the nasal cavities with a flashlight or nasal speculum and check for the presence
of redness, swelling, growths, and discharge
•
Inspect the nasal septum for deviation
•
Palpate the frontal and maxillary sinuses for tenderness
•
Document findings in client’s folder
Requirement for instillation of nasal drop.
Sterile gauze swabs
Nasal drops
Sterile cotton wool buds.
Procedure
1. Explain and discuss the procedure with the patient
2. Consult the patient treatment chart;
a) The type of drug.
b) The date and time of administration.
C) Dose, route and method of administration.
d) Check the validity of prescription.
3. Make available the gauze swabs and /or the cotton wool bud for cleaning of the nasal
passages.
4. Hyper extend the patient’s nares and extend the patient’s neck unless contraindicated.
5. Avoid touching the external nares with a dropper.
114
6. Instill the nasal drop into the nares as prescribed.
7. Request the patient to maintain his/her position for 1-2 minutes.
NB. Each patient should have his/her own medication and dropper.
8. Discard items.
9. Record and report the findings.
EQUIPMENTS FOR THROAT EXAMINATION
Tongue depressor: to suppress the tongue to allow for examination of the mouth and throat
Gloves
Laryngeal mirror for oral examinations.
Posterior laryngeal mirror for posterior rhinoscopy (seeing the inner parts of the nose like the
conchae) Flexible scope to help examine places that are hard to reach.
Penlight to aid inspection
PROCEDURE FOR THROAT EXAMINATION








Inspect the outer lips for symmetry of contour, color and texture.
Put on clean glove and inspect the inner lips and mucosa for color, moisture, texture and
the presence of lesions. Also inspect the teeth and gum
Inspect dentures if any. Ask client to remove complete or partial dentures and inspect for
breakage or warm areas
Ask patient to protrude the tongue and check for color, texture, position, movement
Inspect the base of the tongue, floor of the mouth and frenulum
Inspect the hard and soft palate for color, shape and the presence of bony prominences.
Also check for the movement of the uvula and position by asking client to say “ah”
Inspect the tonsils for size, discharge and color
Document finding
GARGLE: THROAT
Gargle is used to irrigate the throat and to clear the throat of any particles. In most cases, a warm
salt solution may be used making sure it is not warmer than body temperature.
Wokadine gargle could be used or normal saline will do.
EAR IRRIGATION
DEFINITION
Ear irrigation is the process of flushing the external canal with sterile water or sterile saline. It is
used to treat patients who complain of foreign body or cerumen (ear wax) impaction.
PURPOSE
The purpose of ear irrigation is to remove earwax that is obstructing the ear canal to remove a
foreign object lodged in the ear canal. Ear irrigation is most commonly performed on those who
experience a wax building that has impaired hearing and irritated the outer ear canal. Ear
115
irrigation is performed in the emergency department as a first line treatment for a foreign object
in the ear canal. Because it is less invasive than using an instrument.If the object is a live insect.
Some foreign objects may be removed from the ear using irrigation alone, but most require a
combination of both irrigation and the use of instruments by the physician.
INDICATION
Cerumen impaction or a foreign body in the ear.
CERUMEN
Cerumen is a naturally occurring normally extruded product of the external auditory canal. It is
usually asymptomatic, but when it becomes impacted it can cause complication such as hearing
loss, pain or dizziness.
Cerumen can be removed by watchful waiting, manual removal, the use of ceruminolytic agent
and irrigation with or without ceruminolyticpre treatment. When removal becomes complicated
then it is referred to an otolaryngologist (otolaryngology is a branch of medicine and surgery that
specializes in the diagnosis and treatment of disorders of the head and neck.
REQUIREMENT
1. Waterproof cape and disposable towel.
2. Jet applicator tip
3. Apron
4. Light Source
5. Water & Jug
6. Auriscope
7. Receiver
8. Cotton wool
9. Decontamination table
10. Warm irrigation solution to 370C (98.6F)
11. Syringe (500cc for adult, 200cc for kids)
PREPARATION BEFORE PROCEDURE
The patient should be positioned with his or her head bent slightly forward and tilted toward the
unaffected ear his or her shoulder and neck should be covered with a water resistant pad and a
bath towel. The patient should be given kidney shaped basin to hold under the affected ear.
Children, the elderly, or patients who cannot sit up may be positioned or the back with the head
tilted slightly toward the unaffected ear. Again, the shoulder should be covered and or the pillow
with a water resistant pad and a bath towel. If necessary the nurse should obtain assistance to
hold the basin under the ear during the ear irrigation.
CARE DURING PROCEDURE
The Nurse should wash his or her hands and put on gloves. The normal saline or sterile water
irrigation solution be heated. This can be accomplished by placement of the solution bag (bottle)
in hot water or using a microwave. Then the temperature of the solution should be checked
before irrigation is started. The solution should be body temperature or slightly warmer (98.600F
or 37 – 37.8C). Cool irrigation solution is more likely to make the patient dizzy. If using an
116
irrigation syringe, the cap should be rewarded and the first 60cc should be drawn into the
syringe. If using an IV catheter, the needle should be removed and the plastic catheter attached to
the syringe or the IV tubing. All air from the syringe and tubing must be removed. Further, when
an ear irrigation kit is used the pieces should be opened and assembled. The IV tubing must be
primed and filled and the irrigation apparatus should be connected. The patient should have a dry
wash cloth on hand in case the irrigation fluid runs towards his or her face or eyes. The patient
should be informed before the irrigation begins. The patient should be instructed to speak up if
he or she experiences pain or discomfort.
CARE AFTER PROCEDURE
The patient should tilt his or her head toward the affected ear far a few minutes. This will allow
excess fluid to run out. The irrigation apparatus should be removed and the patient assisted with
drying off. The outer ear should be wiped with cotton balls or cotton swab. However, the swabs
should not be placed into ear canal. Irrigation fluid should be discarded into a hopper. Disposable
equipment and gloves should be placed in a trash bag that can be sealed and discarded. Finally the
nurse should wash his or her hands once the procedure is completed.
COMPLICATIONS
Complications of ear irrigation are rare ,but may include trauma to the external ear canal, external
ear infection, pain, nausea or vertigo. Forceful irrigation with high pressure can rupture the
eardrum and force bacteria into the inner ear.
ANTRUM WASHOUT
REQUIREMENTS
A tray with the following:
 A receiver with myles Lichwitz Antrum trochar&cannula
 Higgison’ syringe with adaptor
 A receiver with sinus forceps, nasal speculum, dissecting forceps
 A jug of normal saline
 Receiver for returned fluids
 Receiver for used forceps
 Receiver for swabs
 Anaesthetic spray
 Sponge holding forceps
 Lotion thermometer
 Specimen tubes
 Gauze swabs
 Mackintosh apron
PROCEDURE
 Reassure the client and provide privacy
 Wash and dry hands
117








Sit patient up in a chair and support him with the head tilted back until the antrum
is anesthetized
Place apron around patient’s neck to protect his clothing
Fill the Higginson’s syringes with normal saline at a temperature of 38 degrees
Instruct the patient to hold the receiver at the chest level and lean forward so that
the returned saline will run out of the opening of the antrum through the nose into
the dish
Observe patient for pallor or faintness and return fluid for any abnormality such
as pus and blood and record
Dry patient’s face and remove the apron and cover
Make patient comfortable on a bed and allow him to rest for at least 2 hours/ until
he is fit to go home. Instruct patient to clean the nostrils daily with gauze swabs
moistened with normal saline
Tell patient to report to the facility and see the doctor when the need arises and/or
report for review
Instillation of ear drops
This a method route of drug administration into the ear canal with the purposes of:



Softening the earwax so that it can be removed at a later time
Providing local therapy to reduce inflammation, destroy infective organisms in the
external ear canal
Relieving pain
REQUIREMENTS
 Clean gloves
 Cotton tipped applicator
 Correct medication bottle with a dropper
 Flexible rubber tip (optional) for the tip of the dropper to prevent injury
 Cotton balls
PREPARATION
 Introduce yourself to the client and verify his identity to ensure that the right client
receives the right drug
 Put patient in the required position with the affected ear turned upper most
 Assess the pinna of the ear for signs of redness and abrasions
 Assess for the type and amount of any discharge if present
 Check the patient’s folder for the name of the drug, strength, number of drops and
prescribed frequency
 Check patient’s allergies
 Know the reason why the client is receiving the drug, contraindications,
classification, usual dose range, side effects
118












PROCEDURE
Compare the label on the medication bottle with the client’s record and check the
expiration date
Calculate the medication dosage
Explain the procedure and the importance to the patient and/or family members
Provide privacy and reassure patient
Perform hand hygiene
Clean the pinna and the meatus of the ear canal. Wear gloves if infection is suspected
and use cotton-tipped applicators to clean the pinna and meatus. Ensure that the
applicator does not go into the ear canal. This is to prevent damage to the ear drum.
Warm the medication in your palm/ place it in warm water to prevent nerve
stimulation and pain as well as promote client’s comfort
Straighten the ear canal by pulling the pinna upwards and backwards for client’s who
are over 3 years and administer the drug
Ask client to remain in the side lying position for about 5 minutes
Insert a piece of cotton ball loosely at the meatus of the auditory canal for 15-20
minutes to help retain the medication when the client is up. Ensure not to press the
cotton into the ear canal.
Thank patient and discard tray
Wash and dry hands and document procedure
References
Dougherty L, and Lister S. (2005), the royal marsden hospital manual of clinical nursing
procedures, 6thed, London. Elimination: urinary catheterization, p.330
Suzanne C, Brenda G, Janice L and Kerry H. (2010), Brunner &Suddarth’s textbook of
Medical-Surgical Nursing, 12thed, China, catheterization, p.1372
Stephanie’s Principles and Practice of Nursing (2005), vol. 1, India, catheterization of the
urinary bladder, p.297.
Audrey B., and Shirlee S. (2014), kozier&Erb’s fundamentals of nursing concepts, process, and
practice, 9th ed. U.S.A
119
ASSIGNMENT 1
Describe the following procedures;
1.
2.
3.
4.
Gastric lavage
Tonometry
Visual acuity
Ophthalmoscopy
ASSIGNMENT 2
Describe the following procedures;
120
1. Cranial nerve assessment and reflexes
2. Bladder irrigation
3. Vulva swabbing
121