BASIC NURSING CARE

CONTENTS PAGE
Definition of nursing 1
Hospital setting 1
The cleaning of the ward 1
Qualities of a nurse 2
The approach to the patient 2
Admission of patient 3
Discharges and transfers of patient 4
Bed pan and urinals 4
Sanitary rounds 5
Equipment use for the comfort of the patient 5
Accessories 6
Position use Nursing 6
Principle of bed making 7
Types of bed 8
Changing of linen using top to bottom method
11
Temperature 12
Pyrexia 14
Rigor 15
Requirements for tepid- sponging 16
Pulse 17
Respiration 18
Blood pressure 19
Bath 21
Pressure area/sores 23
Care of the hair 26
Enemata 28
Rectal washout 30
Flatus tub 31
Care of the mouth 34
Administration of drugs
Storage of drugs 41
Common abbreviation used in nursing
Urine 44
Catheterization 44
Urine testing and routine examination 46
Unconsciousness 48
Cross injection 49
Word dressing procedure 50
Removal of stitches 53
Pre and post-operative care 55
Artificial feeding 59
Nasogastric feeding 60
Gastrostomy feeding 61
Gastro-Enteritis 62
Barriers Nursing 63
Last offices 65
Paralysis 65
Meningitis 67
Lumber puncture 68
Diabetes 69
Blood 73
Paracentesis 83
Feeding of helpless patients diets 84
Diets 85
Inhalations 88
Chest Aspiration 89
Oxygen therapy 90

BASIC NURSINGN CARE

As nursing approaches the turn of the century, its focuses have not changed.
Promotion and maintenance of individual, family, and community health
function; management of a healthy environment; and care of the ill are the
centre of nursing.
1. NURSING can thus be defined as ‘’ the art and science of caring for the sick,
the young, the handicapped, the old, the mentally ill and those that are
dying.’’ (Terminally ill patients)
2. NURSING is also defined as the art and science of helping people to care for
themselves, caring for those who cannot care for themselves and helping
those that are dying to die pain free, peaceful and in dignity.
3. It could also be define as ‘’ the professional science that deals with the
unitary man as he evolves from conception right unto death’’
The word nursing brings to mind ideas and images of white uniforms, nursing
caps, syringes and needles, wounds and dressings, bedpans and urinals; for
others such images includes kindness, sympathy, empathy, compassion, and
skill by those beginning their nursing careers.
Modern Nursing was first practiced by Florence Nightingale; hence she is
referred to as ‘’ The mother of modern Nursing’’
There are various Nursing practice settings, and they include the Hospital
setting, the community setting, the private Duty setting, the Health promotion
centres, Long-Term care facilities and palliative care settings.
THE HOSPITAL SETTING
The hospital has various units attached to it, the surgical wards, the medical
wards, the paediatric wards, the obstetric wards, the gynaecological wards,
special care units, intensive care units, orthopaedic department, the operating
theatre, the X-Rays department, consultation rooms, the laundry, the store,
the sewing room, the administrative office, the matron’s office and kitchen.
In the wards, we have the main wards, the private rooms, the sister’s office,
the Doctor’s office, the toilets and bathrooms, the sluices, the kitchenette, the
nurse’ room and the dressing room.
The cleaning of the ward is done by the nurses, the potters and cloak room
attendants under the supervision of the ward sister.
The wards must clean when necessary, it includes high-dusting, damp and dry
dusting of the lockers and window ledges/sill, sweeping, scrubbing and
mopping of the floor and bed making. Attention should be given to the wheels
of trolleys (removing thread and other fabrics from them and then oiling them
at least once a week). Special attention should also be paid to the sluices,
bathroom, urinals and bedpans.
REQUIREMENTS FOR CLEANING THE LOCKERS
1. Bowl with soapy water or diluted anti-septic,
2. Bowl with plain water,
3. Two mops; one to clean using the soapy water and the other to rinse
using the plain water
When cleaning the lockers, it is done from the top to the bottom, the inside of
the lockers are cleaned thoroughly on discharge, or transfer or death of the
patient.
For the inside of bedpans and toilet sits they should be scrubbed using toilet
brush or a short strong broom, and vim or disinfectants.
Requirements for General ward cleaning
Trolley with _ two mops or towels
_ a bowl with soapy water
_ a bowl with clean water
_ Scrubbing brush
_ Long broom for high-dusting
_ Sweeping broom
_ Small shovel
_ Dust bin
The qualities of a nurse
The objective of Nursing is the care and comfort of the patient; hence nurses
are trained to develop those qualities necessary to become well trained and
competent.
Good Nurses are kind, courteous polite, considerate, always cheerful,
observant, helpful and willing to undertake any task they are to perform. They
should be regular, punctual, loyal and honest. They should be interesting and
interested people who endeavour to maintain a lively curiosity in events
outside the hospital; the nurse who can talk of nothing but hospital life
becomes a dull companion resulting to boredom and irritable to the detriment
of both the nurse and the patient.
The nurse should be friendly and tolerant. In any community, the most
popular person is one who exhibits a good nature on-critical attitude towards
other people, thus creating a pleasant atmosphere at all times.
GROOMING
Personal hygiene and health are paramount; if neglected the nurse will be
unable to give her best to the patient. An average of eight hours of sleep is
essential to allow the tissues to rebuild themselves especially the nervous
system. The diet should be non-risking with all the necessary food factors for
the maintenance of good health. Exercises should be taken outdoors in the
open air away; lack of fresh air causes lethargy and tiredness.
THE APPROACH TO THE PATIENT
Nursing is a career in which human relationships are most important factor.
The basic of all good nursing lies in such attributes as kindness, courtesy, and
efficiency. Patients are people with a life outside the ward, a fact which nurses
tend to overlook in their pre-occupation with hospital duties; there may be
anxiety concerning the family or personal problems which may harass the
mind, yet rarely will the nursing staff hear of these worries and anxieties.
Often they are suppressed to the detriment of the patients’ recovery progress.
Lack of privacy is one of the most trying factors in a patient’s life especially in
bathing, toilet rounds and other procedures. The nurse may regard them as
routine in a general ward but the patient may not regard them so, hence may
long for the seclusion of home.
Then new patient should be greeted with a reassuring and cheerful manner,
thus given confidence and making the hospital less frightening, especially to
those nervous and apprehensive. The average patient shows courage in the
face of pain and trouble, but occasionally we meet the unhappy, complaining
type of patient with whom all the resources of the nurse is called upon. You
should try to understand the reason for such behaviour remembering that
pain, worry or fear may be the reason.
Patience, humour, and sympathy are needed to overcome the mental distress.
The patients should not be left unattended behind screens. When carrying out
procedures, do not assume that the patients knows what is about to be done.
Always spend some time to explain to the patient. Sleeplessness may be due
to mental distress or worry of some kind (complete relaxation which is
essential for the promotion of sleep and recovery must be encouraged).
A few sympathetic words may bring reassurance and happier state of mind
when the patient realizes that someone is aware of his inability to sleep. The
sense of loneliness during the night in a strange surrounding is lessened by the
attention of an observant nurse.
ADMISSIONS OF PATIENTS
Admissions to wards are done from the following areas:
1. From waiting list (Booked)
2. As emergencies from the outpatient department
3. They may be written as special cases, i.e. referrals from clinics or
hospitals.
In most cases, the patient is nervous and ill at ease. It is the nurse who is given
the opportunity of extending a cheerful, courteous and reassuring welcome. If
the patient is from a waiting list, he and any person accompanying him should
be given a chair. The patient must not be given the impression that he is ‘’ just
another case’’ or that the nurse is too busy to spare much time, nor should the
relatives feel they are being a nuisance (they should be given a chair and asked
to wait until the patient is settled in the ward).
The Ward-Sister is informed of pending admissions and the arrival of the
patient. Particulars are then taken by the nurse from either the patient or
relatives and they include:-
1. Name and address of the patient,
2. Age and Date of birth,
3. Marital status, religion and sex of patient,
4. Occupation
5. Religion
6. Name, address and telephone number of the nearest (Next of kin (N.O.K)
7. Name of the physician or surgeon in charge of the patient.
A consent form for operation or anaesthesia must be signed by the patient if
an adult or the N.O.K. if the patient is under age or incapable of signing. When
all the particulars are completed, the patient is taken to the bed side and
introduced to the nearby patients, shown the toilet, bathroom and kitchen.
Next the Temperature Pulse Respiration (TPR) and Blood Pressure (B/P) are
taken and recorded. A specimen of urine should be obtained and tested
routinely for sugar, protein, ketoses, bile blood etc. and the result recorded.
For seriously ill or unconscious patients, valuable or documents or large sums
of money should be checked in the presence of the patient or relatives; listed
cross-checked by another nurse and handed over to the sister for safekeeping.
The patient’s clothes may be sent home or listed and labelled and stored until
called for. Any drug in the patient’s possession should be given to the Ward-
Sister for the Doctor’s inspection and approval. Emergency admissions
brought in by ambulance or admitted from the OPD are put straight into bed
and blanket-bathed if necessary; the presence of scars, rashes or
abnormalities should be noted.
ADMISSION OF CHILDREN AND INFANTS
The basic procedure for children is the same as for an adult but effort is
necessary to reassure the child whose confidence must be gained. No sign of
haste or impatience must be shown. The mother should be present
throughout the admission procedure. Take the TRP and B/P and record. An
identity bracelet carefully checked by the mother may be attached to the wrist
or ankle.
It is usually unnecessary to bath and put a child to bed admitted from a
waiting list; children associate bed with punishment. Parents should be
advised to bring a favourite toy to be left with the child; this form a link with
home, some hospitals have facilities for the mothers to live in particularly if
the child is less than 5 years old.

1. Address of parent if different from child,

2. Religion; if christened from the child,
3. What infectious diseases the child has had,
4. Whether the child has been vaccinated or immunized, and against
diseases and when.
If a baby is admitted, then
1. The type and amount of food he is having,
2. The times at which feeds are due,
3. Breast feeding mothers should be accommodated in the hospital.
DISCHAGE AND TRANSFER OF PATIENTS
When a patient is to be discharged, the relatives are informed one or two days
before hand; so that clothes and personal belongings are returned to him,
arrangements made for transportation, and arrangements made to re-
accommodate him. When leaving the ward a receipt is obtained for any
valuables or documents or money in safekeeping before being handed over to
him.
Instructions are given to the patient or relatives or both regarding
appointments medicines to be taken, dressings and limitation of activities. The
patient should be escorted from the ward either by a nurse or by a porter, and
seen off the premises. If the patient is to be transferred to another hospital or
ward, he should be told when and why he is being transferred, one or two
days before so that any undue anxiety may be allayed. The relatives are also
informed in advance of the pending transfer. Immediately a patient is
discharge or transferred, the bed is stripped and the linen and blankets are
sent to the laundry. Disposable sheets are destroyed; others are washed,
disinfected, dried and stored on rollers. The lockers, bed-tables, and beds
must be washed and disinfected, and the bed made up with clean linen. All
notes and charts must be carefully filed and sent to records department.
BED PANS and URINALS
BED PANS:-
They are made of enamel, porcelain, stainless steel, rubber or thermoplastic
material. The stainless steel type has largely replaced the enamel type that is
easily chipped and roughened. The porcelain is heavy and breaks very easily.
The rubber or thermoplastic is rough and does not break or chip and is much
quieter when in use; but because plastic is a poor conductor of heat hence it
feels cold to touch and must be heated before use. It is shaped to fit contours
of the buttocks. Cover the bedpan when giving and removing it. They are
flushed with water after use then cleaned with brush and soapy water and
sterilized.
HOW TO GIVE A BED PAN
i. Screen the bed for privacy.
ii. Cover the bedpan and bring to the bedside.
iii. Place the patient on the bedpan by:-
a. With the left hand under the lower back lift the patient and place
bedpan underneath the buttocks with the right hand
 b. Ask the patient to dig his heels on the bed, and raise his hips.
Expose the buttocks by drawing the pyjamas or pulling up the
night-dress. Place the bedpan underneath the patient.
iv. All patients should be supported on the backrest when using the
bedpan. If the patient is very ill or weak, the nurse should stay at the
bedside.
HOW TO REMOVE THE BEDPAN
i. If the patient is unable to attend to himself, the nurse should assist
him to use the toilet tissue.
ii. Remove the backrest, ask the patient to roll on side and slip out the
bedpan or alternatively to flex his knees, dig his heels on the bed and
then raise his hips.
iii. Clean patient with toilet tissue and leave in this position
iv. Cover the bedpan, remove and take to the sluice immediately.
v. Inspect the contents for abnormalities before emptying.
vi. Wash the bedpan thoroughly under running water using brush and
rise well.
vii. Put the bedpan in the bedpan rack.
viii. Meanwhile the patient should wash his/her hands in a bowl of water
provided and then dry with towel.
ix. If the bed linen is soiled, it is changed.
x. The patient is made comfortable.
xi. The screen is pulled back.
xii. If specimen is required, it is placed in the specimen container which is
labelled with the name, age, and ward of the patient, the type of
specimen the date, and time of collection and then sent to the lab
with the requested form.
URINALS:-
They are supplied in glass, enamel, thermoplastic or stainless steel. It is usual
to cover the urinal when giving and removing it. They are flushed with cold
water after use and then cleaned with map or brush and then sterilizes.
HOW TO GIVE URINALS
I. Cover the urinal and bring it to the bedside.
II. Screens may or may not be required.
III. Hang the cover at the end of the bed and offer the urinal to the
patient.
 IV. Leave the patient alone.
V. After sometime, return to the patient, remove and cover the urinal.
VI. Empty at once, if a record is being kept measure the urine and chart at
once
VII. Rinse the urinal well, clean with mop or brush and put to drain on the
rack.
VIII. Wash your hand and dry well
IX. Make the patient comfortable
X. If a specimen is required, it is collected in a special contain, properly
labelled, sent to the lab with requested form
SANITARY ROUNDS
It is a usual practices to give bedpans and urinals at definite times to patients
confined to bed e.g. early in the morning and after each mealtime. However
some patient s required attention at other times than routine time and this
should be attended to promptly. The ward is closed to all except the nursing
staff during the sanitary rounds. Privacy should always be afforded by the use
of screens.
5

REQUIREMENTS FOR THE ADMINISTRATION OF BEDPANS

The requirements should be assembled on a trolley except if the patient very
pressed.
Top shelf of trolled -- bowl with water to wash the hands
- Soap dish with soap
- Towel to wipe the hands after washing them
Bottom shelf of trolley - bedpan with bedpan cover
- Toilet roll to be used in cleaning the patient.
If the patient has soiled himself then clean linen and clean pyjamas suit must
be included on the trolley. Also brown cotton wool and two face flannels must
be included in the requirements.
EQUIPMENTS USED FOR THE COMFORT OF THE PATIENT (ACCESSORIES)
ACCESSORIES: These could be defined as special equipment used for the
added comfort of the patient; they are used according to the condition of the
patient and the type of nursing care required. They include:-
1. Bed cradles: They are usually made of metal or enamel or plastic, and
dome shaped. They are used to take the weight of the bed linen from
the body. When in use, a light blanket is used to cover the patient. They
 are used for patients with wounds of the lower part of the body, patients
with oedema, burns or fractures.
2. Bed rest or Backrest: They are used to support the patient in the upright
position. Often they are part of the bed-head and can be adjusted. Or
they can be portable made of wood or tubular steel with canvas strips to
support the pillows. In the absence of the bed rest chairs can be
improvised as bed rest.
3. Air-rings: These are hollow, rubber rings, which are inflated to form a
cushion, on which the patient sits or rests part of the body. They are
used to prevent pressure or bedsores. They be covered with cotton
before being used. They can be improvised by using gauze and cotton
wool or sponge.
4. Fracture Boards: This is a board placed underneath the matters to
prevent it from sagging. They are used for patients with fracture of the
lower extremities, the pelvis, the spine and ribs. They are also used when
needed for firm support after spinal injuries or operations or amputation
of the lower limbs.
5. Bed blocks: They are used to raise the head or foot of the abed by
resting the castors of the bed inside the cup like depressions at the top
of the blocks. The bed can also be raised by elevators, which may be
attached to the bed or portable. Bed blocks are used in case of shock,
after the administration of spinal anaesthetic, in case of vaginal or rectal
bleeding, in severe oedema as in severe heart disease, in the
administration of retention enema and pessaries.
6. Sandbags: As the name implies, these are bags of different sixes filled
with sand. They are used to support or immobilize part of the body e.g.
fractures of the slower limbs, pelvis and the body in case of fracture of
the spine.
7. Bed table: This enables the patient to eat and write in bed. It is also used
to support a patient on with heart condition; the bed table is draw across
the bed, a soft pillow is placed on it and patient leans forwards on it; this
enables the patient to rest his back.
8. Sputum-mug: this can be of stainless steel or enamel with an attached
lid. It is used to collect the sputum of the patient. Before being used it is
half filled with diluted disinfectant or anti-septic. It is used in patient with
severe cardiac or respiratory conditions.
9. Foot-rest: This used to support the patient in the proper position
especially in patient who have been in bed for a long time; it prevents
the patient from slipping down the bed and prevents foot drops.

10. Side rails: These could either be attached to the bed or portable.
They assist the patient when he wants to get up, it prevents him from
rolling off the bed and provides support when the patient wants to walk
round the bed.
POSITIONS USED IN NURSING
The position use to nurse a patient depends on the type of disease, the
signs and symptoms and the treatment being given. Then position has an
important bearing on the progress, comfort and recovery of the patient.
TYPES OF POSITIONS USED IN NURSING:-
1. Recumbent or Supine Position: The patient lies flat on his back on the
bed with one pillow under the head to ensure complete bed rest
2. Semi-recumbent position: The patient lies on the back in bed with
two or three pillows under the head. This position is often adopted
during convalescence. It gives the patient the opportunity to view the
ward whilst at the same time he is resting.
3. Lateral position: The patient lies on the left/right side with buttocks at
the edge of the bed and the knees drawn up towards the chin. One
pillow is placed under the head. This position is used for the
administration of enema and suppositories. It is also used for
unconscious patients but in this case no pillow is used. Again this
position is used for rectal examination.
4. Upright or Fowler’s or sitting up position: The backrest applied to the
bed and 3 or 4 pillows arranged on it either lengthwise or in an
armchair fashion. This allows the patient to sit upright in bed. A
sandbag or footrest is placed at the foot of the bed to prevent foot
drop or the patient slipping down the bed. The patient is encouraged
to move the legs around if possible to prevent thrombosis. This
position allows efficient drainage after abdominal operations. It assists
breathing in severe respiratory or cardiac conditions. It encourages
personal interest in the ward; the patient feels much better when
sitting up in bed than when lying flat in bed.
5. Sim’s position: this is an exaggerated form of the lateral position. The
patient lies with the head and chest on a pillow and the left arm lying
behind the back. The knees are flexed with the right more than the
left. This position is used for vaginal and rectal examination.
6. Dorsal position: The patient lies on the back with the knees raised.
One pillow is placed under the head. It is used for vaginal treatment
and for abdominal examination.
7. Prone position: The patient lies facing downwards with the head
turned to the one side. A pillow is placed under the head and another
one placed under the ankle to prevent pressure of the toes on the
bed. This position is used for patients with surgery or injury on the
back.
8. Semi prone position: The patient lays half on the side and half on the
abdomen. No pillows are used instead the head is titled back and
supported in that position by placing the hands underneath the head.
This position is used for unconscious patient.
9. Lithotomy position: the patient lies on the back with the knees flexed,
and the thighs raised and separated. The buttocks are brought to the
edge of the couch.
10. Trendelenbug position: - The patient lay on the back with the
couch titled at 45; the head being lower than the rest of the body. The
legs and knees are flexed over the adjustable lower section of the bed
or cough. This is position is used for gynaecological operation.
11. Knee-chest or Genupectoral position: The patient is placed on the
bed on her knees with chest resting on a pillow on the bed. She rests
her elbows on the bed or puts her arms above her head. The thighs
should be vertical, the legs horizontal and the buttocks held up. This
position is used for rectal and vaginal examination.
 PRINCIPLES OF BEDMAKING
The primary aim of bed making is:-
(a)To make the patient fresh and comfortable
(b) To make the ward net, tidy and fresh.
Two nurses should make a bed, making it smoothly, no creases and without
undue disturbance to the patient. One nurse working on each side of the bed.
RULES TO BE OBSERVE IN BED-MAKING
1. As with all nursing procedures, the hands are washed with soap under
running tap.
2. The patient should be informed the bed screened, nearby windows
closed and fans put off, to avoid chilling; the patient should be unduly
exposed.
3. All clean linen required and a receptacle for solid linen should be
collected before the bed is striped.
4. All linen is removed, they are folded neatly in three and placed over a
bed stripper or two chairs placed back to back at the foot of the bed or
discarded in the soiled linen receptacle.
5. Two nurses should make up a bed; working smoothly together without
jerking the bed or the patient. There should be no unnecessary talking
between them; all talking should involve the patient.
6. The linen and all articles used to make up the a bed should never be
allowed to touch the floor or they will be contaminated by bacteria in
the dust thus spreading infection.
7. Do not shake the beddings as this spreads dust and bacteria leading to
infection; no linen must cover the patient’s face.
8. A blanket must be left next to the patient when stripping the bed and
the top sheet slipped out from under it.
9. All creases and crumbs should be removed or brushed out from under
the patient. The bottom sheet and the draw sheet should be pulled and
the ends firmly tucked under the mattress.
10. Pillows are removed, shaken and placed comfortably in position
under the patient with the open ends away from the direction of the
door.
11. The top sheet should be loosed at the bottom to allow movement
of the legs and toes. Everything needed by the patient should be within
easy reach of the patient.
TYPES OF BEDS
1. The occupied or open bed,
2. The unoccupied or closed bed,
3. The special beds:- the fracture bed,
the plaster bed
the post-operative or operation bed,
the emergency admission bed,
the cardiac bed,
the divided or amputation bed,
THE OCCUPIED BED: - As the name implies, there is a patient in it. When
making the bed, asks the patient politely if mobile to take a walk or site in a
chair, if immobile the bed has to be made with the patient in it using the top
to bottom method or the side-to side method. The bed can also be made
whilst the patient is taking his bath. Sometimes the patient may not be
allowed to be turned from side to side, then the sheet should be prepared by
rolling it across the width instead of the length of the bed and it is put in from
the top instead of the side of the bed.
REQUIREMENTS FOR MAKING AN OCCUPIED BED: 1 large mackintosh, if
necessary
2 large sheets
1 draw sheet
1 draw mackintosh
1 counterpane
1 blanket
2 pillows
2 pillow cases
THE UNOCCUPIED OR CLOSED BED: - This is bed without a patient in it; it is
made in preparedness to receive a patient.
1. The articles are collected and brought to the bedside. They are arranged
on a chair at the foot of the bed in the order they are required.
2. The large mackintosh, the bottom sheet, the draw mackintosh and the
draw sheet, are spread on the bed in the correct order.
 3. The pillow is placed at the top of the bed with the open away from the
door.
4. Spread out the top sheet allowing 20 inches more at the top, the foot
end is tucked in making neat envelop corners.
5. The blanket is spread and tucked in at the foot-end;
6. The top end is folded over the blanket and the side tucked in
7. The counterpane is spread, the bottom end mitred and the top end
brought over the pillows.
THE EMERGENCY ADMISSION BED:- This bed is made is preparedness to
receive an emergency admission; we do not know exactly what is wrong with
the patient. Hence the bed is made to accommodate whatever circumstance
the patient presents; all accessories and resuscitation equipment’s are
brought to the bedside in readiness to combat the situation.
REQUIREMENT FOR EMERGENCY ADMISSIOM BED
-1 large mackintosh -2 large sheets -1 draw mackintosh
-2 draw sheets -1 pillow with case -1 counterpane
-2 admission blankets -TPR tray -B.P. apparatus
-Emergency tray -drip stand -oxygen apparatus
--Bed elevators/blocks -bed cradle -sand bags
-fracture board
The bottom of the bed or the foundation of the bed is made up as far as the
draw sheet, with one pillow on a chair at the bedside. The bed is then covered
with an admission blanket, which is tucked in. The second admission blanket is
folded lengthwise and placed on top. The top sheet and counterpane are
folded into a pack and placed on the bed over the admission blankets.

THE EMERGENCY TRAY COUNTAINS:-

- a receiver with artery forceps, mouth gag tongue, tongue
depressor or spatula, tongue holding forceps, sponge-
holding forceps, non-toothed dissecting forceps;
- galipot with swabs
- galipot for soiled swabs
 - Vomit bowl.
THE FRACTURED BED
The fracture bed is made for patients with fracture of the spine, fracture of
the lower limbs, fracture of the ribs, Patients with spinal surgery, and
amputation of the lower limb,
Requirements: - 1 large mackintosh -2 large sheets
-1 draw mackintosh - 1 draw sheet
-2 pillows with case -1 counterpane
- Fracture board - 2 sand bags
- bed blocks - 1 bed cradle
- 1 light blanket - small mackintosh and towel
Method: - The fracture board is placed underneath the mattress and the bed
made up in the usual manner up to the draw sheets. The small mackintosh
and towel, the sandbags and bed cradle are placed in position in the region of
the fracture. The top sheet is spread and the foot end mitred; the
counterpane is spread, tucked in and mitred in. The drip stand is needed if the
patient is in shock and needs intravenous infusion.
THE CARDIAC BED: - This type of bed is used for patients with heart failure;
heart disease; pneumonia or severe respiratory conditions; patient with neck,
chest and major abdominal operations. This type of bed requires the patient
to be nursed in the semi-upright position.
REQUIREMENTS: -- 1 large mackintosh -2 large sheets -1 draw mackintosh -1
draw sheet
- 4 or 5 pillows with case - 1 counterpane - 1 bed rest or backrest -
bed table with a soft pillows - Sputum mug - air ring - Oxygen apparatus -
footrest
Method: - The bed is made in the usual manner with the draw mackintosh and
draw sheet nearer the head of the bed. The bed rest is placed in position. The
pillows are placed on the bed rest arranged either lengthwise or in armchair
fashion. The top sheet and counterpane are spread and the foot end mitred.
The bed table with soft pillow is placed over the bed to allow the patient to
lean forward for a change of position and to allow the patient or rest the back.
The spread of his arm resting on the bed table aids respiration by increasing
the capacity of the thoracic cavity.
THE PLASTER BED: - This bed is use for patients with plaster of Paris applied to
the lower limbs. The bed is made up in the same way as for a fracture bed.
Mackintosh should be put over the bottom sheet under the p.o.p until it is dry.
A bed cradle is required. The top sheet and counterpane are turned back at
the bottom to allow free air to circulate. The limb may suspend on a Balkan
Beam if it is heavy or it can be elevated on an extra pillow with a plastic cover
(i.e. a jaconet.) The patient needs a blanket next to him to keep him ward.
Requirements: --1 large mackintosh -2 large sheets
-1 draw mackintosh -1 draw sheet
-1 counterpane -1 blanket
-1 bed cradle -2 sand bags
- 1fracture board -3 pillows
- 3Pillow cases -1 jaconet
THE POST OPERATIVE OR OPERATIVE BED: - This bed is made in preparedness
to receive a patient from the operation theatre or after doing some special
laboratory test or after special x-Ray. The bed is made up again with fresh
linen as far as the draw sheet. At the head of the bed, the small mackintosh
and towel are placed if the patient vomits. The top sheet counterpane are
folded into a pack and placed at the centre of the bed to keep it warm. The
pillow and extra blanket are placed in a chair at the side of the bed, the
blanket is used to cover the patient if he chills or goes into shock.
REQUIREMENTS FOR POST-OPERATIVE BED
-2 large sheets -Emergency Tray

-1 large mackintosh -Drip stand

- Draw mackintosh -Suction Machine –Resuscitation tray
-1 draw sheet -Oxygen Apparatus
-1 counterpane -Bed blocks/ Bed-elevators
-2 pillows with pillow cases - Extra blanket
- Small mackintosh and towel
-Temperature Tray and B.P. Apparatus
DIVIDED OR AMPUTATION OR WINDOW BED:-
This bed is made to accommodate patients on whom amputation of the lower
limbs, the hands or the fore-arms has been done. The sump can be viewed
through by lifting the bottom half of the bed linens without disturbing the
patient.
Requirements for a divided bed
- Large mackintosh -3 large sheets -2 counterpanes
- 1 draw mackintosh -1 draw sheet -1 bed cradle
- 1 small mackintosh and towel - 2 pillows with case -2 sand bags
- 2 bed blocks - tourniquet (out of sits) - 1 blanket
Method; - The bed is made up in the usual way as the draw sheet as in a
simple bed. Then the top part of the bed is made in two halves (the top half
and the bottom half) over the bed cradle.
The top half
1. To make the top half, one large is spread over the bed with more at the
top.
2. The first counterpane follows as for the top sheet and is folded into two.
3. The lower end of the top sheet is folded over the counterpane and the
top end of the top sheet folded down over the counterpane.
The bottom half
1. To make the bottom half, the second large sheet is spread over the bed
and tucked at the bottom.
2. The second counterpane is spread over the sheet and tucked in at the
bottom.
3. The counterpane is folded down and the top end of the top sheet
brought down over the folded counterpane.
The stump can be viewed by lifting either the top half or the bottom half of
the bed clothes without disturbing the patient.
N,B :- Before the top half and bottom half are made, after the draw sheet,
bring it alongside the patient and then transfer the patient to the fresh bed.
CHANGING OF BED LINEN USING THE SIDE TO SIDE METHOD
 1. Wash your hands and assemble the requirements on a trolley and bring
the trolley to the bedside (i.e. the right hand side of the bed)
2. Inform the patient, close nearby door and windows, put all fans, and
screen the bed (this is to ensure privacy and to avoid chilling the
patient).]
3. Place two chairs back to back or a bed stripper at the foot of the bed.
4. Strip the counterpane, fold loosely in three and place on top of the chairs
5. Loose the top sheet but do not remove.
6. Remove all pillows except one, which is pulled to one side of the bed
7. Without exposing the patient, the hands and feet are crossed.
8. The patient is rolled one side (i.e. facing the side to which the pillow is
pulled; the nurse on that side supports patient with one hand on the
shoulder and one hand on the buttocks)
9. Whilst the patient is being supported by Nurse A, Nurse B on the other
side untucks the draw sheet, the draw mackintosh and bottom sheet;
and rolls them separately under the patient
10. The clean bottom sheet, the draw mackintosh, and the draw sheet
are then rolled separately under the patient.
11. It is now the turn of Nurse B, to roll the patient to his back, pull the
pillow to her side, roll the patient to her side and then support the
patient.
12. Nurse A now pulls the soiled linen from under the patient and then
pulls the clean linen into position.
13. The patient is tolled back to his back; the linen straightened out
leaving no creases and then tucked in.
14. The clean top sheet is then placed on top of the used or soiled one.
The used or soiled one then slipped out from underneath without
exposing the patient.
15. The top sheet is tucked in loosely and the counterpane spread and
trucked in.
16. The pillowcase is changed and then arrange comfortable with the
open ends away from the doorway.

CHANGING OF BED LINEN USING THE TOP TO BOTTOM METHOD

This method used for patients in the upright position (i.e. patients with heart
failure, heart diseases, pneumonia pleurisy, with chest or neck or abdominal
operations and conditions.
METHOD
1. Wash your hands, assemble all the requirements on a trolley and bring
to the bedside.
2. Inform the patient, close nearby doors and windows put off all fans and
screen the bed.
3. Place two chairs back to back or a bed stripper at the foot of the abed.
4. Strip the counterpane, fold loosely in three and place on top if the chairs
or beds tripper.
5. With the patient covered by the top sheet, he is lifted to the bed
supported either with the use of a bed table pillow or by a nurse.
6. The top part of the bed is stripped and remade with clean linen.
7. The patient is lifted to the top part of the bed and the bottom part of the
bed made properly leaving no crease.
8. The top sheet is then remove and replaced with a clean one without
exposing the patient.
9. The pillows are re-arranged and the counter
10. The patient is left comfortable in bed.

TEMPERATURE
This is a state or degree of coldness or warmness of a substance or body. The
thermometer is the instrument used to measure and register the
temperature. The Thermometer works on the principle that all matter expand
or Celsius scale(C) and the Fahrenheit Scale (F).
THERE ARE VARIOUS TYPES OF THERMOMETERS; NAMELY:-
i. The Wall thermometer.
 ii. The Lotion Thermometer
iii. The Bath Thermometer
iv. The Clinical Thermometer
Increase in Body Temperature: - Alteration of body functions are reflected in
alteration of the temperature, pulse, respiration and Blood Pressure (T.P.R.
and B.P.) hence they are referred to as the Body’s Vital Signs. The temperature
must be kept or maintained within a normal range, which is essential for
normal functioning of the body cells and the central nervous system. Body
temperature is regulated by chemical and physical means through the heat
regulating centre in the hypothalamus in the brain.
INDICATION FOR TAKING BODY TEMPERATURE
i. To get a baseline temperature on admission for future reference.
ii. To assess the patient’s condition on admission.
iii. To monitor the patient’s temperature thereby detecting any deviation
in the patient’s condition.
iv. To determine whether the patient is improving or deteriorating (i.e.
whether he is responding to treatment or not).
THE CLINICAL THERMOMETER
This is used for measuring the body temperature. It is made of glass with a
hallow tube running through the centre tube when heated. The Mercury will
not return to the bulb until the thermometer is shaken because there is a
constriction in the tube which prevents this; care should be taken when
shaking the thermometer that is held firmly and does not come into contact
with nearby objects or it will break.
The average body temperature is often marked by an arrow at 37.2 ᴼC or 98.4
ᴼf. The time needed to register the temperature is 2-5 minutes or at least the
time stated on thermometer.
1. Fahrenheit to Centigrade
Subtract 32, Multiple by 5 and Divide by 9.
2. Celsius to Fahrenheit
Multiple by 9, Divide by 5 and then Add 32.
SITES FOR TAKING THE TEMPERATURE
There are four suitable sites for taking body temperature but as the reading
varies with the different sites, the same site must be used for the same
patient.
THE SITES ARE AS FOLLOWS:-
i. The Mouth
ii. The Axilla )- add 1 ᴼF
iii. The Groin )- Lower than in the mouth
iv. The Rectum - Temperature is about 1 higher than in the mouth.

Taking the Temperature in the mouth

The mercury is shaken down to below 35 ᴼC or 95 ᴼF and the thermometer
wipe with a swap before being placed underneath the tongue. The lips should
be closed not the teeth. The patient should not talk whilst the thermometer is
in place. The thermometer is left for the requisite time, removed and the
temperature read at eye level. The thermometer is wiped with a wet swab,
shaken and place in the container.
The patient should be sitting or lying down.
The temperature should not be taken immediately after a bath, a hot or cold
drink or after smoking because these affect the temperature.
The temperature should not be taken in the mouth of very young children,
unconscious patients, delirious and irresponsive patient, where there is
difficulty in breathing or losing the mouth, where there is disease or injury of
the mouth.
Taking the Temperature in the Axilla of Groin
The skin should be thoroughly dried before placing the thermometer in
position. The thermometer must be in contact with the skin on all sides with
no clothing intervening. The arm is drawn across the chest and held in place
until the temperature is registered. In the case of the groin, the leg is crossed
and held in position for the required time. After taking the temperature in the
axilla or groin, 1ᴼ or 0.5ᴼ is added to the temperature indicated on the
thermometer before charting it on the temperature chart. This is because the
temperature is lower in the groin and axilla them in the mouth.
Taking the Temperature in the Rectum
A special thermometer with a rounded, thick bulb is used and it is kept
separate from the others. The bulb is lubricated with Vaseline or KY Jelly or
liquid paraffin, the buttocks separated with the thumb and forefinger of one
hand, the thermometer inserted gently into the rectum for about 1’’ or 2.5 cm
and held there until the prescribed time indicated on the thermometer. This
method is used for small children and babies. The child’s legs must be firmly
and gently controlled by the nurse whilst holding the thermometer in place; if
necessary two nurses are needed. After removal, the thermometer is wiped
first with a wet swab and then with a dry swab, and then read at eye level. It is
then washed in soapy water, rinsed and replaced in the container. As the
rectal temperature is higher than the oral temperature, 1 ᴼ or 0.5ᴼ is
subtracted from that registered on the thermometer.
Ranges of body Temperature
Normal Range -97ᴼF-99ᴼF (36.1ᴼC-37.2ᴼC)
Sub- Normal Range -95ᴼF-97ᴼF (35ᴼC- 36.1ᴼC)
Hypothermia -below 95ᴼF or 35ᴼC
Pyrexia/Hyperthermia -99ᴼF- 104ᴼF (37.2ᴼC-40ᴼC)
Hyper Pyrexia/hyperthermia -above 104 ᴼF (40ᴼC).
Average Body Temperature -98.6ᴼF or 37.0ᴼC
PYREXIA/HYPERTHERMIA/FEVER
This is an elevation of the body temperature above normal range i.e. 99 ᴼF or
37.2 ᴼC, above104 ᴼF or 40 ᴼC it is referred to as hyperpyrexia. The presence
of fever signifies infection or reaction to foreign proteins in the body or injury
to the brain or lesion of the upper portion of the spinal cord.
Pyrexia helps to increase the body defences (bacteria are either destroyed in
high temperature or their growth is interfered with). The formation of
antibodies takes place in high temperature. Phagocytosis is increased in
pyrexia. However if the temperature is too high the body will fail to function; if
the temperature rises above 105ᴼF, the enzymes and proteins will coagulate
and hence death will occur.
CAUSES OF PYREXIA
i. Invasion and multiplication of microorganism in the body (INFECTION) or
inflammation due to any other cause
ii. Toxic conditions
iii. Continuous pain
iv. External exposure to extreme heat over a prolong period
v. Direct interference with heat-regulating centre in the hypothalamus
 vi. Head injuries

Symptoms of Pyrexia
i. There is an increase in the T.P.R
ii. Anorexia
iii. Generalised malaise (a feeling of general discomfort and illness)
iv. Headache
v. The skin is dry
vi. The tongue and mouth are dry and patchy
vii. The urinary out-put is reduced
viii. The patient may be lethargic (condition of drowsiness, which cannot be
overcome by will)

Nursing Care of Pyrexic Patient

i. Bed rest; the room must be well ventilated, shaded and quiet
ii. Monitor the T.P.R. ¼ hrly or ½ hrly
iii. Give copious oral fluid or I.V. fluids to replace lost fluids and to cool the
system
iv. Give cold sweet drinks and light fluid diet rich in protein and calorie
because of the burning tissues (in pyrexia there is increased metabolism)
v. Maintain a fluid balance chart
vi. Do mouth care because of the nausea, anorexia and dried mouth and
tongue
vii. You can either expose the patient covering only the genital area under
circulating air or tepid sponging depending on the level of pyrexia
viii. Some form of anti-pyretic drug may be given
ix. Observe the bowel movement
x. Urine and blood test must be done before any drug is given

RIGOR
The sudden onset of a severe illness is often marked by a rigor, which is
characterized by involuntary shivering.
It is sudden disturbance of the heat-regulating centre and it commonly ushers
in an acute illness (e.g. Malaria, Pneumonia, Pyaemic infections). It is marked
by three definite stages
i. The Cold Stage
 ii. The Hot Stage
iii. The Sweating Stage

The Cold Stage: - The patient complains of feeling very cold and shivers
violently. The skin may be pale and cold or blue (due to vaso-constriction).
There is chattering of the teeth due to the shivering. The patient rolls himself
up into a ball so as to expose very little of the body surface to the cold.
Nursing Care:- In this stage, you give bed rest extra clothing and blanket. Close
nearby windows and doors. Give hot drinks if the patient can control the
shivering sufficiently to drink. Monitor the vital signs. Reassure the patient.
Call the doctor.
The Hot Stage:- The skin becomes hot and dry. The patient complains of thirst,
weakness and headache. The temperature continues to rise and the pulse
becomes rapid. The respiration is rapid and laboured.
Nursing Care:- Some of the extra blanket may be removed with care so as not
to chill the patient. Cold compress may be applied to the forehead and a cold
drink given.
The Sweating Stage:- This follows the hot stage after a length of time. There is
profuse sweating. The clothing and bedding may become damp. The
temperature falls and the pulse rate slows down during this stage.
Nursing Care:- The patient should be warmly covered and the perspiration
wiped from only the face until the sweating has ceased. The patient is dried
thoroughly with a warm towel. The clothing and bedding are changed.
After the rigor, the patient is exhausted and needs skilled nursing care. The
patient must not be left alone until recovery is complete. The temperature is
taken ¼ hrly and recorded throughout the rigor. The bed should remain
seemed and the patient left to rest until recovery is complete
TEPID SPONGING
This is treatment carried out to reduce an extremely high temperature (i.e.
101 ᴼF or 38.3ᴼC to normal. It allows water on the skin to evaporate thus
allowing the body to lose heat. The temperature usually falls to about 1-1.5ᴼ
but if the patient complains of chills or a fall of more than 2 ᴼF then stop the
tepid sponging.
REQUIREMENTS FOR TEPID SPONGING ON A TROLLEY
TOP SHELF OF TROLLEY
 1) Wash Bowl
2) Jug or Tap Water or cold water
3) Small Bowl with Ice
4) Temperature Tray
5) Talcum Powder
6) 1Bath Towel
7) Small bowl with six face Flannels or Sponges
BOTTOM SHELF OF TROLLEY
1) Clean Linen
2) Clean Clothes
3) 2 Bath Blankets
4) Bedpan with Cover and Toilet Roll
5) Receptacle for Soiled Linen

Normally the procedure last for about 20 minutes but it could be stopped if
the patient feels chilled or the body temperature drops by more than 2ᴼ
PROCEDURE
(1)Inform the patient and briefly explain the procedure to the patient.
(2)Screen the bed and offer bedpan to the patient.
(3)Put off fans; close nearby doors and windows.
(4)Bring the prepared trolley to the bedside
(5)Take and record the vital signs.
(6)Untuck the bed; turn the patient to one side; roll one bath blanket
underneath the patient and cover him with the other bath blanket.
(7)Undress the patient
(8)Using one face flannel, wrap a piece of ice and put on the forehead.
(9)Dip the four flannels, in the bowl of tap water or cold water and put one
in each axilla and each palm.
(10) The sixth flannel is dipped into the water and without squeezing, it
is used to sponge the patient with long- sweeping strokes leaving beads
of water on the skin to evaporate; we start with the arm away from you,
then the arm close to you and then the chest and the abdomen.
(11) If the water gets warmer, then either cold water is added or the
water is changed
(12) When the upper part of the body has been sponged, the armpit is
dried thoroughly and after 4-7 minutes the temperature is taken,
recorded and compared with the previous temperature.
 (13) If the temperature is still high, the upper part of the body is
covered and lower-part exposed; the flannels are removed from the
axilla and placed in the groin.
(14) The lower limbs are then sponged for about 5 minutes; the
temperature is taken again after 5-7 minutes
(15) If the temperature is still high, the patient is turned on the side, the
back sponged and the pressure areas treated.
(16) After the procedure has been completed, the bath blankets are
removed; the body properly dried and powdered; the patient dressed;
and the linen straightened or changed accordingly.
(17) The patient is lightly covered; given plenty of cold drinks to flush
the system, thereby further reducing the body temperature.
NB
(1)If after the whole procedure the temperature is still high, then the
procedure may be repeated after 2 hours and the ward sister or doctor
informed.
(2)After the procedure, the patient is made comfortable; mouth care is
done; given plenty of cold drinks and a light nourishing diet rich in
calories and protein.
(3)Continue to reassure the patient and do general observation.

PULSE
This is an important guide to the condition of the patient. Each time the left-
ventricle contracts it forces blood into aorta which was already full of blood.
The aorta expands to accommodate this additional blood. The blood, which
was, present in the aorta before the ventricular contraction is now on into the
nest section which in-turn expands and so on. Thus a wave of expansion
constitutes the pulses and it travels rapidly over the arteries. Hence the pulse
can be defined as a wave of expansion which occurs in artery as blood is
pumped through it with each contraction of the left ventricle of the heart. It is
felt when a superficial artery passes over a bone. The estimation of the pulse
rate should be done with the patient at rest, sitting or lying position. Normal
pulse rate is 60-100 beats per minute. (bpm)
Sites for Taking the Pulse
i. Temporary artery (at the temple)
ii. Carotid artery (at the base of the neck)
 iii. Brachial artery (inside the groove of the elbow)
iv. Facial artery (over the angle of the lower jaw)
v. Radial artery (at the wrist)
vi. Femoral artery (at the groove in the groin)
vii. Popliteal artery (at the back of the knee)
viii. Dorsalis pedis (on top of the foot)

Ranges of Pulse rates

 Adult— 60-100 bpm
 Children (6-10yrs) 90-100 bpm
 Infants/neonates—120-140 bpm

The pulse rate becomes slower with increase in age.

When taking the pulse, the Rate, Rhythm and volume are noted.
The Pulse Rate: - This is the speed at which the heart is beating; it is the
number of beats per minute. The rate is very constant in a healthy person in
the resting stage but is increased by exercise, emotional disturbance and in
diseases.
Rhythm: - Is the regularity or irregularity of the heartbeat. The interval
between each beat should be of equal duration. But in diseases of the heart,
the rhythm is irregular. If the rhythm is irregular, the pulse rate should be
taken for a full minute instead of 15 or 30 seconds.
Volume: - Is the strength of the heart beat and indicates the amount of blood
in the artery at each contraction of the ventricles. If the heart is beating
strongly, it imparts a big pulse wave to the arterial system and the artery is felt
to undergo considerable increase in size. On the other hand, a weak heart
beat produces only a small pulse wave with only a small increase in size of the
artery.
Hence the volume can be described as:
i. Full or Bounding; where it cannot be obliterated by the fingers
ii. Thready pulse; which feels like a thread under the fingers and can be
easily obliterated
iii. Imperceptible pulse; which cannot be felt.

Factors in Health that influence the Pulse Rate

 i. Position of the Patient; the pulse is more rapid when standing or moving
about than when lying down or sitting relaxed
ii. Sex; the pulse is increased during sexual intercourse
iii. The rate is slightly more rapid in females than in males with a difference
of about 5 BPM.
iv. Age; the pulse rate is more rapid in children and infants than in adults
v. Exercise; the pulse rate increases after a vigorous exercise
vi. Emotional State; the pulse rate increase after an emotional upset e.g.
fright, anxiety, anger, worry and surprise
vii. Pain; the pulse rate increase when the patient is in pain
viii. Disease; the pulse rate increase in feverish conditions
ix. Haemorrhage; the pulse rate increase in case of bleeding
x. Drugs; some drugs increase the pulse rate whilst others reduce the pulse
rate (e.g Digoxin)
xi. The pulse rate increased during digestion

TACHYCARDIA: - This is the term used to denote a quick action of the heart;
hence the pulse rate is rapid and above 100 bpm.
It is common in the following condition: -
i. Pyrexia
ii. Thyrotoxicosis (increased activity of the thyroid gland).
iii. Haemorrhage
iv. Anaemia
v. Drug like atropine, amyl nitrite
vi. Weak heart muscle
vii. Dyspepsia
viii. Emotional Disturbance

BRADYCARDIA: - This means an excessively slow heart beat resulting in a slow

pulse rate i.e. less than 60 bpm and some of the common causes are: -
i. Stimulation of the vagus nerve due to increased intra-cranial pressure as
a result of cerebral Haemorrhage, tumors or injury to the brain
ii. Large doses of narcotic drugs e.g. heroin, morphine.
iii. Disease of the heart tissue
iv. Starvation
v. Myxoedema
Sinus Arrhythmias: - This is an irregularity of the heartbeat . The strength of
the beat is unaffected but the rate of the pulse increase with inspiration and
decrease with expiration. It is quite common in children and during
convalescence from febrile condition. It is not abnormal and does not indicate
heart disease.
But when taking the pulse, it should be done for a full minute.
RESPIRATION
This is the breathing in of atmospheric air (inspiration) and the breathing out
of used air (expiration).
Composition of air
Inspired Air or Expired Air or Used
Atmospheric Air % Air %
Oxygen 20 16
Carbon dioxide 0.04 4
Nitrogen 79 79
During inspiration, the intercostal muscles raise the ribs and the diaphragm
lowered thereby enlarging the thoracic cavity hence the lung capacity; air is
sucked into the chest.
During expiration, the ribs are lowered and the diaphragm rose to push out
used air from the chest.
There are two phases of respiration:
i. External Respiration: - Which is the exchange of gases between the
atmosphere and the blood through the medium which is the lungs.
ii. Internal Respiration: - Is the exchange of gases between the body cells
and the blood. The rate of respiration is the number of breaths per
minute.

It is higher in children and infants. The older we become the slower the
respiratory rate. There is usually a ratio between respiration rate and pulse
rate; usually it is about 1 respiration to 4 heart beats.
The normal adult respiratory rate is 16 – 24 breaths per minute, and may be
increased by excitement, exertion and disease.
Normal respiratory rate should be taken when the patient is at rest and
without his knowledge; this to avoid any conscious change in the rate, depth
and character of the breathing.
Types of Respiration
Sighing or yawning: - This is also known as air hunger. There are long, deep
inspiration indicating a need for more oxygen. It is common in case of
haemorrhage, uraemia and diabetic coma.
Dyspnoea: - This is difficult breathing caused by conditions of the lungs,
condition affecting the circulatory system (anaemia) and lesion of the
respiratory centre. It may occur at rest or on exertion. Breathing is laboured
and difficult.
Orthopnoea: - This is very difficult breathing with the patient unable to breath
except in the erect position i.e. sitting upright. It is caused by cardiac
conditions, asthma, pneumonia, pulmonary oedema.
Apnoea: - This is temporary caesation of respiration.
Stertorous: - This is a noisy snoring type of respiration which occurs in deeply
unconscious patients and may be due to the tongue slipping back and blocking
the airway. A peculiar hissing respiration may be noted in patients in uraemic
coma.
Chyne-Stoke: - In this type of respiration the breathing gradually increases in
rate and depth to a peak and then gradually decreases in rate and depth until
it finally stops. Then there is a period of Apnoea for a few seconds, and then
the cycle starts again with the breathing gradually increasing in depth and
rate. This type of breathing is characteristics in patients with renal disease,
heart disease, cerebral conditions, and patients with conditions of the
circulatory system. It is a sign of impending death in very ill patients.
BLOOD PRESSURE
BLOOD PRESSURE: - This is the pressure or force which the blood exerts on
the walls of the artery in which it is contained. It is measured in millimetres of
mercury (mmHg.)
INDICATIONS FOR TAKING BLOOD PRESSURE
1. To establish the patients baseline blood pressure on admission
2. To assist in diagnosing the patient
3. To assess the patient for drug therapy
4. To establish the patients baseline Blood Pressure before surgery
5. To monitor and identify any fluctuation
FACTORS THAT MAINTAIN NORMAL B.P.
1. Peripheral Resistance
2. The volume of the Circulating Blood
3. The viscosity of the Blood
4. The pumping action of the Heart
5. The Elasticity of the walls of the Blood Vessels

Any interference with any of these factors will interfere with the blood
pressure. The B.P. in children is lower than in adults (as age proceeds the B.P.
becomes higher). As the B.P. varies with different people hence a baseline B.P.
is taken on admission.
There are two types or phases of blood pressure.
1. Systolic 2. Diastolic
THE SYSTOLIC PRESSURE: - This is the pressure blood exerts on the walls of
the arteries following the contraction of the ventricles and the opening of the
aortic valve. It is the greatest pressure. It ranges from 100 – 140 mmHg.
THE DIASTOLIC PRESSURE: - This is the pressure the blood exerts on the walls
of the arteries when the ventricles are at rest and the aortic valve is close. It
ranges from 60 – 90 mmHg.
The difference between the systolic and diastolic pressure is the pulse
pressure and is usually 40 mmHg.
NORMAL RANGES FOR SYSTOLIC BLOOD PRESSURE
I. Children (under 10yrs) - 100 mmHg.
II. Adolescent /Young Adults (13 – 30yrs) - 100 – 120 mmHg.
III. Middle Age (39 – 60yrs) - 120 – 140 mmHg.
IV. Old Age (over 60yrs) - 140 – 150 mmHg.
FACTORS IN HEALTH THAT INFLUENCE NORMAL BLOOD PRESSURE
1. AGE: It is lower in children then in young adults which is also lower than
in middle age
2. SEX: Women tend to have a lower blood pressure than men
3. EXERCISE: In exercise the pressure tends to increase than in rest
4. EMOTIONS: (such as fear, surprise, anger, joy) can alter the blood
pressure, i.e. the blood pressure becomes elevated.
 5. POSTURE: The blood pressure is higher when lying down or sitting
relaxed than when standing up. The blood pressure in some people
suddenly drops when standing up thereby causing them to collapse (this
is called posture hypo tension).
6. TIME OF THE DAY: It is lower in the morning than in the evening because
of the rest during the night and the activities during the day, but it is the
reverse for those working the night.
7. DIGESTION: The blood pressure tends to rise up during digestion.
NORMOTENSION: This is normal blood pressure and it ranges from:
Systolic - 100 to 140mmHg
Diastolic - 60 to 90mmHg
HYPOTENSION: This is when the blood pressure is persistently low;
i.e. Systolic less than 90mmHg
i.e. Diastolic lesser than 60mmHg
HYPERTENSION: This is abnormally persistently raised blood pressure;
i.e. Systolic greater than 150mmHg
i.e. Diastolic greater than 100mmHg
MEASURMENT OF BLOOD PRESSURE
This is done using the stethoscope and the sphygmomanometer. It is done
when the patient is lying down or sitting up. It should not be done
immediately after the patient has completed a task (e.g. walking, running,
talking); instead after such task the patient should be given at least ten
minutes to rest before the blood pressure is measured. Also the blood
pressure should be measured using the left arm with the sphygmomanometer
at heart level except if there are prevailing factors preventing this e.g.
1. An I.V. fluid on the left arm
2. Injury or disease on the left arm.

BATHING
There are three types of bath.
 1. A WASH: Is done to freshen up patient. It could be done in bed or in the
bathroom. It is done during the course of the day, to cool down the
patient, before meals, when the patient wakes up from sleep and before
the patient changes his bedclothes. It involves washing of the Face,
hands, feet and mouth.
2. THE BIG – BATH: Which is done in the bathroom using a bath – tub,
showers or kettle.
3. THE BED OR BLANKET BATH: Which is done in bed by two nurses
WHY DO WE BATH A PATIENT
i. To make the patient fresh and comfortable
ii. To keep the skin clean and Healthy
iii. To improve the odour in the ward
iv. To promote physical, mental and emotional well-being of the patient
v. It provides an opportunity for the nurse to examine and observe the
patient
vi. It acts as a therapeutic measures (as in the treatment of scabies,
ringworm etc).
BED OR BLANKET – BATHING: - This is done for the following patients.
i. Patients with fracture (e.g. \\ of the Femur, Pelvis, Spine, Tibia and
fibula, Skull)
ii. Unconscious patients
iii. Paralysed Patients
iv. Patients with Major Surgery
v. Patients with Cardiac or severe respiratory conditions
REQUIREMENTS FOR BED – BATHING
The items are assembled on a trolley and the procedure carried out by two
nurses working as a team.
Top Shelf of Trolley
i. Bath Bowl
ii. Jug of Hot Water and Jug of Cold Water
iii. Soap in a dish

iv. Two faces towels or flannels in a bowl

v. Bath - Thermometer
 vi. Receiver with nailbrush, scissors and cotton – swabs
vii. Talcum powder
viii. Comb or hairbrush
ix. Tooth brush and paste in a mug
x. Shaving stick and cream for males
Bottom Shelf of Trolley
i. Two bath blankets
ii. Bath Towel
iii. Clean set of linen
iv. Clean clothes
v. Bed pan and cover with toilet tissue
vi. Soil linen receptacle
vii. Bucket for used water
Method or Procedure for Bed Bathing
i. Inform and reassure the patient
ii. Screen the bed, close nearby windows and put off all fans
iii. Take your prepared trolley to the bedside and offer the bedpan
iv. Two chairs are placed at the foot of the bed back to back
v. Wash your hands
vi. Remove the pillows leaving only one
vii. The linen are removed as far as the top sheet and either this is left
covering the patient and changed at the end of the procedure OR bath-
blankets are placed in position, one covering the other underneath the
patient
viii. The patient is then undressed
ix. The washing should be done quickly without unduly exposing the patient
x. Pour a quantity of cold water into the bath-bowl and then gradually add
hot water until it reaches the correct temperature (i.e. approximately
100 F). If no bath thermometer is available, you test the water with the
back of your elbow.
xi. You then bath the patient in the following order: the face, the back of
the ears, the neck, the arms (doing the one away from you first), the
chest, the abdomen, the lower limbs starting with the one away from
you first.
xii. The water and the first face flannel are changed. The patient is turned on
his side and the back of the head and the back done with the second
flannel.
xiii. The patient is turned on his back and given the flannel to do his genital
area if he could.
xiv. The water is changed after doing lower limbs or if the water becomes
too soapy, or dirty or cold.
xv. As each area is being done by the first nurse, it is dried and powered by
the second nurse.
xvi. When the bath is completed, the bottom bath – blanket is removed, the
bed-clothes worn and the bed remade.
NB:
i. It may be necessary to cut the nails of the patient
ii. Two nurses should do a bed-bath
iii. When bed-bathing a patient all pressure areas should be done
iv. Where tow folds of skin are in contact special care must be taken to
ensure complete dryness.
v. The patient should be asked at the beginning whether or not he wants
soap on his face
vi. Following a bed bath, the mouth and hair should receive attention (the
hair is combed or plaited for females).
vii. For males attention is given to the beard before bathing the patient
BATHING THE PATIENT IN THE BATHROOM OR BIG BATH
Requirements: -
 Bath towel
 Soap in a soap dish
 Face flannel or sponge or sappo
 Clean bedclothes
 Comb or hair brush
 Tooth brush and paste in a mug
 Powder and cream or Vaseline’s
Method
i. The bathroom and the bath tub is cleaned
ii. All requirements should be collected and taken to the bathroom
 iii. All windows are closed but the door is not locked instead a screen is
placed in front of the door or round the bath
iv. The bathtub is then prepared by running first the cold water and then
the hot water testing the water temperature with a bath thermometer
or the back of the elbow as you go along (100 F – 105 F).
v. Before the patient commences the bath a chair or bench should be
placed for the patient to sit on.
vi. During the patients' absence in the ward, the bed should be made up
with clean linen
vii. Whilst the patient is bathing, the nurse should be close at hand, assisting
if necessary and observing for any abnormalities.
viii. If necessary the nails should be cut and the patient shaved.
ix. After the bath, the patient is escorted to his bed
x. The bathtub and the bathroom are cleaned and disinfected, the floor
dried, the windows opened and screen removed
NB: - If the patient feels faint in the bathtub, pull out the plug of the bathtub
so that the water drains out; do not attempt to lift the patient on your own.

PRESSURE SORES/PRESSURE AREAS

PRESSURE SORES: - Are sores that are liable to develop on patients who are
confined to bed for a long time. They can also be called bedsores. They are
formed over bony prominences or where two folds of skin overlap. Patients
with poor nutritional status are more adopt to develop bedsores.
It is the aim of the nurse to prevent this wherever possible. They may be the
result of inferior nursing care because in most cases they can be prevented.
The first signs of bedsores or pressure sores are
1) Redness of the skin
 2) Soreness of the skin
3) Discomfort
4) Hotness
Which if neglected will result to a crack or damage of the skin leading to an
open wound.
Compressions of the capillaries deprive the tissues of nutrients and allow the
build-up of metabolic waste in the tissues which result in death of the tissues
(anoxia.) The compressions of the capillaries stop the blood flow in the area.
Because of the rapidity with which the bedsores may develop, frequent
attention must be given to all areas of the body that may become affected.
Once an open sore is formed it is difficult to heal and need constant dressing.
PRESSURE AREAS: - There are areas over bony prominences or where two
folds of skin overlie; the areas which a bedsore may occur.
COMMON PRESSURE AREAS
1) At the back of the head or occipital
2) The shoulder blades
3) The elbows
4) The lumbar vertebra
5) The hips
6) The sacral areas of the buttocks
7) The Ankle, heels and toes
8) The knees
9) Under the breast, armpit and groin for fat people
CAUSES OF BEDSORES
1) PRESSURE: - From lying or sitting too long in one position. Immobility
combines the pressure of his body on the bed or against a splint cuts off
the blood supply to the area and eventually tissue necrosis.
A very sick person, a patient immobilized in a splint, an unconscious patient
or a paralyzed patient are all unable to change their positions.
2) FRICTION: - From creased or patched sheets, from crumbs in the bed or
from carelessly handled bedpans. The skin becomes inflamed and sore
from constant rubbing.
3) MOISTURE: - As during incontinency of urine and faeces, and during
excessive sweating. If the skin is constantly wet, it becomes sodden,
 unhealthy and very liable to ulceration. Incontinent patients need
constant attention and the use of barrier cream.
4) IRRITATION: - Caused by rashes or excreta. These causes the skin to
irritate and the patient scratched
until the skin becomes sore and breaks open.
5) INJURY: - Cracks or abrasions may arise from careless handling of patient
by the nurse’s rings, wrist watches or long nails.
TYPES OF PATIENT LIABLE TO GET BEDSORE
1) Helpless patient } They cannot turn
2) Unconscious patients } for themselves
3) Paralysed patients }
4) Emaciated or Under-nourished or very thin patients (there is no muscle
or flesh to act as cushion)
5) Extremely fat or obese patients (the excess weight causes pressure on
the bed stopping the blood supply to the part).
6) Fractured patients (the pain may prevent the patient from turning also
the POP may cause compression and tightness.
7) Incontinent patients (the wetness causes the skin to become sodden
unhealthy and liable to ulceration.
Bedsores are slow to heal up and act as a focus for infection and toxaemia
hence they should be prevented.
PREVENTION OF BEDSORES
The following are important in the prevention of bedsores. The objective is
to stimulate the circulation of blood to the part to keep the tissues nourished.
This can be assisted by:
1) Frequent changing of the patient’s position at 2hrly to 4hrly intervals
depending on the patient’s condition.
2) Early ambulation of patients where possible
3) No rings, wristwatch should be worn and nails should be short
4) Good nourishment and plenty of fluids
5) Careful bed-making, removing creases and crumbs from the bed and
frequent changing of wet sheets, not turn or patched sheet should be
used.
6) Careful position of the limbs; not allowing them to lie on top of each
other
 7) Care when giving bedpans and good general nursing care
8) The use of accessory equipment’s such as air-ring, ripple-beds, air-beds,
pads and soft pillows. These are used to relieve pressure on a bed
patient
9) Routine treatment twice a day or more often where necessary (but too
frequent use of soap removes the natural protective oil in the skin
making it more liable to damage).
Complications can include the following:

 Anaemia
 Fistula formation (urethral, faecal)
 Osteomyelitis
 Pyarthrosis (infectious arthritis)
 Altered cells may become malignant
 Autonomic dysreflexia (sudden onset of high blood pressure)
 Renal failure
 Amyloidosis (progressive deposition of amyloid in organs)
 Bacteraemia
 Sepsis


ROUTINE TREATMENT OF PRESSURE AREAS

REQUIREMENTS: TOP SHELF
(1)Wash bowl with warm water
(2)Soap dish with soap
(3)Barrier cream (zinc in castor oil cream)
(4)Talcum powder
(5)Face flannel in a bowl
(6)Surgical spirit
BOTTOM SHELF
(1)Bath towel
(2)Clean linen
(3)Clean clothing
(4)Mackintosh and towel
(5)Brown wool in receiver
(6)Incontinent pads
(7)Receptacle for soiled linen (if necessary)
 (8)Receptacle for soiled pads
(9)Bedpan and tissue at bedside
METHOD FOR ROUTINE TREATMENT
(1)Explain to the patient what is to be done (why and how)
(2)Screen the bed, put off fans and close nearby windows
(3)Bring the trolley to the right hand side of the bed towards the foot end
and test the water
(4)Position the patient and expose only the part that is being treated by
turning down the bedclothes; do not over expose.
(5)Put the bath towel underneath the part of the patient that is being
treated
(6)Dip your hand in the water, apply soap to your hand and massage the
part being treated in a circular motion with your palm until the soap
disappears
(7)Use one of the face flannel dampened with the water and wipe the part
clean
(8)Use part of the bath towel to dry up the area well and then dust the area
with talcum powder.
(9)If the patient is incontinent of faeces, remove the incontinent pad, clean
up the patient with brown wool, then clean with soap and water,
massage the area well, dry up the area and apply Barrier Cream.
NB: - (1) In very bony or obese patient, the surgical spirit is used after the area
has been dried and before the area is dusted with the talcum powder.
(2) When Barrier Cream is used, the pressure area need not be done more
than once a day except if soiled by excreta; the changing of positions is
necessary at 2hrly or 4hrly intervals as this relives pressure and allows the
blood to flow freely to the different parts. The Barrier Cream acts as a
barrier between the skin and moisture and also assists healing.
(3) All pressure areas should be done when bed bathing a patient.
CARE OF THE HAIR
AIM: - (1) To promote mental and physical health
(2) To prevent tangling and matting of the hair
(3) To prevent infestation by pediculi (lice)
The hair should be combed or brushed at least twice a day. Long hair is most
comfortably dressed by plaiting. On admission of new patients, periodically
the hair and scalp should be inspected for pediculi
INSPECTION OF THE HAIR FOR PEDICULI (HEAD LICE)
REQUIREMENTS: -
(1)Brush and fine – toothed Comb
(2)Bowl of Dettol
(3)Bowl of swabs
(4)Receiver for soiled swabs
(5)Cape mackintosh
METHOD: - When this method is being done the nurse should stand behind
the patient. The cape mackintosh is placed round the shoulder of the patient.
The hair is combed or brushed free of tangles. The fine toothed comb is
dipped into the Dettol. Small strands of hair are taken and combed.
Afterwards the comb is wiped with a swab and then inspected for pediculii or
lice. If the head is found infested with pediculii or their nits (eggs) it should be
treated at once.
A head infested with pediculii or their nits, it is called a Verminous Head.

TREATMENT OF VERMINOUS HEAD

Requirements: -
(1)Cape mackintosh and jaconet (i.e. Mackintosh in the form of a pillow
case)
(2)Brush and comb in a receiver
(3)Bowl of cotton wool swabs
(4)Receiver for soiled swabs
(5)Galli pot with lotion (DDT emulsion or lethane oil or camphor in nut oil)
(6)Head cover for patient
(7)Gown and head cover for the nurse
METHOD: - (1) The nurse protects herself with gown and head-cover before
commencing; she should not bring her head close to the patient’s head.
 (2) The procedure is explained to the patient bring the requirements to the
bedside and the bed screened
(3) The patient is positioned in the upright (fowler’s position) or semi-
recumbent position.
(4) The Cape mackintosh is placed round the shoulders of the patient and
the pillows protected with Jaconet
(5) The hair is divided into 8 parts, four on each side of the midline
(6) The lotion is applied to the scalp using swabs.
(7) The scalp is then massage with the fingertips to ensure thorough
distribution.
(8) Following the application, the patients head is covered using the head-
cover.
(9) On daily basis, the head is uncovered and the hair combed to remove
dead lice and their nits.
(10) The head is covered for eight days after which the hair is washed.
NB: IDDT emulsion (Dichloride – dipheny – trichloroethane) is used, then the
hair should be washed 48hrs after application

WASHING OF THE HAIR IN BED

REQUIREMENTS: Top Shelf of Trolley
METHOD: - (1)The nurse protects herself with gown and head-cover before
commencing; she should not bring her head close to the patient’s head.
(2) The procedure is explained to the patient bring the requirements to the
bedside and the bed screened
(3) The patient is positioned in the upright (fowler’s position) or semi-
recumbent position.
(4) The Cape mackintosh is placed round the shoulders of the patient and
the pillows protected with Jaconet
(5) The hair is divided into 8 parts, four on each side of the midline
(6) The lotion is applied to the scalp using swabs.
 (7) The scalp is then massage with the fingertips to ensure thorough
distribution.
(8) Following the application, the patients head is covered using the head-
cover.
(9) On daily basis, the head is uncovered and the hair combed to remove
dead lice and their nits.
(10) The head is covered for eight days after which the hair is washed.
NB: IDDT emulsion (Dicholoro – dipheny – trichloroethane) is used, then the
hair should be washed 48hrs after application
WASHING OF THE HAIR IN BED
REQUIREMENTS: Top Shelf of Trolley
(1)Comb and hair brush
(2)Large wash bowl
(3)Jug of hot water
(4)Jug of Cold water
(5)Shampoo or soap
(6)Small jug to bail water
(7)Bath bowl
BOTTOM SHELF OF TROLLEY: -
(1)Bath towel
(2)Large mackintosh
(3)Bath blanket
(4)Cape Mackintosh and towel
METHOD: - There are two methods used to wash the patient’s hair in bed.
METHOD 1: - The mattress is pulled down to the foot of the bed to expose the
spring at the top of the bed. Or alternatively the top of the mattress is folded
inwards to expose the spring at the head of the bed.
METHOD 11: - Sit the patient up in the bed, bring a bed table towards the
patient and put the bath bowl on it into which the hair is washed.
METHOD 1 in Details: -
- Inform the patient, screen the bed, close nearby windows and put off
nearby fans
- Pull the mattress down to expose the top spring of the bed OR fold the
top of the mattress to expose the spring at the top of the bed
- The patient’s gown is slipped down below the armpit and chest
- Cover the patient with the blanket
- The cape mackintosh is placed round the shoulder and chest over the
bath blanket
- Two or three pillows are placed under the patients shoulders to support
him whilst the head rest over the bath bowl
- The bath bowl is placed on top of the large mackintosh at the top spring
- The shampoo is poured on the head and well massage into the scalp
using the tip of the fingers
- The hair is then rinsed into the bath bowl with the water from the large
wash bowl. It is then re-shampooed and re-rinsed
- The bath bowl is removed; the hair dried the mackintosh removed from
the bed, the mattress pull back or unfolded
- The cape mackintosh and the bath blanket are removed
- The patient gown replaced
- The hair is combed or brushed
- If the scalp is dry or full of dandruff and cannot be washed frequently,
then the scalp can be rubbed with a mixture of surgical spirit and water
or Vaseline.
ENEMAS
Enema is a fluid injected into the lower bowel through the rectum. The most
frequent use of an enema is to relieve constipation or for bowel cleansing
before a medical examination or "procedure". In standard medicine an enema
may also be employed for diagnostic purposes ( barium enema), as a vehicle
for the administration of food, water or medicine, as a stimulant to the
general system, as a local application and, more rarely, as a means of reducing
temperature and as a form of rehydration therapy (proctoclysis) in patients for
whom intravenous therapy is not applicable.
TYPES OF ENEMAS
Sedative Enema: - This is a retention enema. It is made of 6 – 20mls of starch
and 1 – 2mls of opium. It is used to stop diarrhoea. It is given slowly and the
foot of the bed elevated.
Magnesium Sulphate Enema: - As it attracts fluid from the tissues to the
bowel, it is used as an evacuant enema and is used in cases of raised Intra-
Cranial pressure. The solution is made with 60 drams of MgSo4 crystals to
200mls water. As olive oil enema, it is followed later by enema saponis.
Barium Enema: - This is given for diagnostic purpose and is used during special
x-rays of the lower bowels
Glycerine Enema: - This is an evacuant enema suitable for small children.
About 5 – 10mls of glycerine added to 10 – 20mls of warm water is injected
into the rectum with a fine rectal catheter using a 20mls or 60mls syringe.
CONTRA-INDICATIONS OF ENEMA
1. If the patient is suffering from paralytic ileus and intestinal obstruction
2. Colonic obstruction (in cases of growths)
3. Gastro-intestinal surgery
4. Gynaecological surgery
OBSERVATIONS MADE AFTER AN ENEMA IS GIVEN
1. The colour, quantity and consistency (i.e. soft or hard) of stools passed
2. Observe if any blood, parasite, pus or foreign body is passed
3. Observe if the enema is tolerated or not
4. Observe if the result is satisfactory or unsatisfactory and if all the fluid
injected is return back
5. If a retension enema is given observe if it is retained or not
6. Observe the general nature of the patient for shock
7. Observe for enema rash
REQUIREMENT FOR ENEMA SAPONIS
TOP SHELF OF TROLLEY
1. Bowl with enema apparatus (i.e. funnel, rubber tubing, connector, gait
clip and rectal catheter)
2. Measuring jug with 1-2 pints of solution (i.e. 30mls of enema soap to
600mls of hot water)
3. Bowl with swabs
4. Receiver for soiled swabs
5. Receiver with a pair of artery forceps
6. Lubricant i.e. Vaseline or KY Jelly
7. Lotion Thermometer
8. Wooden spatula or glass rod
BOTTOM SHELF OF TROLLEY
1. Mackintosh and draw-sheet
2. Bedpan with cover and tissue paper
3. Extra linen
4. Receptacle for soiled linen
METHOD FOR ADMINISTRATION OF ENEMA SAPONIS
 1. 1 – 2 pints of enema solution is prepared at 100 – 105 F (so that when it
is ready for use the temperature would have dropped to body
temperature
2. The patient is asked to empty his bladder
3. The procedure is explained to him
4. The bed is screened, nearby windows closed and fan put off
5. The trolley is brought to the bedside
6. The patient is positioned in the left lateral position with the buttocks
right at the edge of the bed and the knees well flexed towards the chin
7. The mackintosh and draw-sheet are placed underneath the buttocks of
the patient
8. The tip of the rectal catheter is well lubricated
9. All air is expelled from the apparatus by running some amount of the
fluid through and then fastening with the gait-clip or forceps
10. The catheter is then inserted through the anus for about 10cm/4".
11. Some amount of the solution is poured into the funnel and the clip
released.
12. The solution is allowed to run slowly the rate being regulated by the
gait-clip or by lifting and lowering the funnel
13. Whilst the fluid is flowing slowly, the patient is advised to breathe
slowly and deeply through the mouth (this is to reduce intra-abdominal
tension). When the required amount has been injected, the catheter is
carefully removed.
The patient should be encouraged to hold the enema for a few minutes to
ensure satisfactory result. A bedpan is given with the patient in a satisfactory
position. Before leaving the patient, he should be observed for faintness,
weakness, malaise or nausea. The result of enema should be observed and
reported.
If the enema is not returned back, the nurse should assist in cleaning the
patient, giving a bowl of water and soap to wash his hands, and towel to dry
them, soiled linen changed and the patient made comfortable.
On completion, the catheter is either disposed off or washed under running
tap and then sterilized in disinfectant or by boiling. The remainders of the
apparatus are washed in hot soapy water.
RECTAL WASHOUT
 This is carried out when it is necessary to clear the lower bowel and the
rectum of faeces, as before barium enema, before rectal examination, before
operation on the rectum or lower bowel, before sigmoidoscopy and I.V.P.
REQUIREMENTS TOP SHELF
1. Bowl with rectal catheter, rubber tubing, connector, funnel and clip
2. Lubricants i.e. Vaseline or K.Y. Jelly
3. Bowl with swabs
4. Receiver for soiled swabs
5. Large jug with six or more pints of water or saline at 40 C or 105 F
6. Lotion Thermometer
7. Receiver with forceps

BOTTOM SHELF
1. Waterproof sheet for the floor
2. A bucket or large bedpan to receive the returned fluid
3. Extra linen
4. Mackintosh and draw-sheet
5. Receptacle for soiled articles
METHOD FOR RECTAL WASHOUT
The patient is prepared as for giving enema. The waterproof sheet and bucket
or bed-pan is placed on a chair near the bed. The rectal catheter is lubricated
and the air is expelled out. The catheter is inserted for about 10cm. Some fluid
is poured into the funnel; the clip released allowing the fluid to flow slowly, as
sudden distension of the rectum may cause the patient to return the fluid.
When one pint has been given, it is siphoned back by inverting the funnel over
the bucket. The process is repeated until the fluid returning is clear.
Accurate measurement of the fluid given and that returned must always be
made. At the end of the process, the patient is cleaned and made comfortable.
The apparatus is cared for as enema. Before rectal wash-out, enema should
first be given, preferable the enema is given at night and the wash-out in the
morning.
FLATUS TUBE
Flatus or flatulence is the accumulation of gases in the intestines or stomach
causing them to distend or stretch. It is caused by: -
1. Swallowing of too much air
2. Some foods e.g. milk, cheese, beans, eggs, sweet potatoes etc.
3. Gastritis (this is inflammation of the stomach).
4. Dyspepsia (this is associated with the upper GIT, characterized by a
feeling of fullness, discomfort, nausea, anorexia).
A flatus tube is used to relieve the distension and discomfort
A flatus tube is different from a rectal catheter in that the eye of the flatus
tube is at the end whereas that of the catheter is at the side.

REQUIREMENTS
1. Bowl with swabs
2. Bowl with warm water and disinfectant
3. Bowl with flatus tube, connector and rubber tubing
4. Lubricant
5. Receiver for soiled swabs
6. Receiver with forceps
7. Mackintosh and towel
8. Receptacle for soiled articles
METHOD FOR PASSING FLATUS TUBE: - The patient is informed and asked to
empty his/her bladder. The bed is screened, nearby windows closed and fans
turned off. The bed linen is turned down exposing only the buttocks. The
patient is placed in the left lateral position with mackintosh and towel
underneath the buttocks. The bowl with water and disinfectant is placed on a
chair near the bed. The flatus tube is lubricated and gently inserted into the
rectum with the free end of the rubber tubing under the water. It is left in
position for about 10 – 15 minutes or until all the flatus has been expelled.
When the flatus is being passed, bubbles will appear in the water. The patient
should not be left alone until the treatment is completed.
 The amount of flatus passed must be noted and reported. On completion,
the tube is removed, the patient cleaned and made comfortable, and the
apparatus cared for as in enema.
NB: Before passing a flatus tube, the following may be observed: -
1. Reassure the patient thereby reducing anxiety
2. Advice the patient to reduce carbonated drinks
3. Give hot tea and lime without milk
4. Give peppermint water diluted in hot water or give peppermint/diamint
to suck
5. Failure to these, then a flatus tube is passed.
SUPPOSITORIES
These are cone-shaped gelatin coated preparation containing medications
which are inserted through the rectum. They melt at body temperature
thereby releasing the drug.

INDICATION OR REASONS FOR SUPPOSITORIES

To evacuate the lower bowels of faeces instead of using enema and rectal
washouts) before x-rays of
1. the lower bowels, before operations on the lower bowel and rectum, to
relieve constipation
2. To administer a drug when it is not possible to be taken orally
3. To relieve local discomfort e.g. in haemorrhoids
4. To soften hard stools thereby making defecation easier e.g. glycerine
suppository
REQUIREMENTS ON A TRAY
1. Prescribed suppository in a receiver
2. Patient’s prescription sheet
3. Lubricants e.g. KY Jelly or Vaseline
4. A pair of disposable gloves or fingerstalls
5. Bowl with swabs
6. Receiver for soiled articles
7. Small mackintosh and towel
8. Bedpan and tissue if evacuant suppository is used
METHOD FOR INSERTING SUPPOSITORY
The patient is informed and asked to empty the bladder. The bed is
screened, nearby windows closed fans turned off. The bed-linen is turned
down exposing the buttocks. The top half of the patient is protected with a
small blanket. The patient is placed in the left lateral position with the
mackintosh and towel underneath the buttocks and the knees well flexed
towards the chin. The gloves are worn on the right hand and the index finger
well lubricated. The prescription sheet is checked again the suppository. The
suppository is then inserted into the anus and pushed up the rectum with the
index finger.
The patient is encouraged to retain it as long as possible if it is an evacuant
suppository.
It is important to know whether the suppository has been given for bowel
evacuation or whether it has to be retained.
If an evacuant suppository is used, the patient is either accompanied to the
toilet or given a bed-pan. The patient is cleaned and made comfortable. The
contents of defecation are noted and reported.
CONTRA-INDICATIONS FOR SUPPOSITORIES
1. In chronic constipation
2. In paralytic Ileus
3. In Intestinal obstruction
oesophagus, the stomach and the proximal end of the duodenum, and also
incases of carcinoma of the stomach.
a. Greenish Vomit: This may be due to the presence of bile. It occurs in
cases of malaria.
b. Dark Brown Faecal Vomit: This type of vomit is a serious sign and it
occurs in cases of intestinal obstruction.
c. Bright Red-Blood Vomit: This may be the result of bleeding from the back
of the nose, or the throat and tongue.
NAUSEA: This feeling of sickness without actually vomiting; there is only the
urge or feeling to vomit.
SPUTUM: This is a sticky fluid expelled from the respiratory organs by
coughing. The quantity and type of sputum should be noted. The sputum
should be collected with a sputum-mug. The use of handkerchief is forbidden
because the sputum may be loaded with bacteria. The sputum may have the
following appearance: -
a. Rusty – Coloured Streaks: - This is typical of pneumonia. The blood has
altered in colour and is mixed with mucoid.
b. This is clear mucus tenacious in character (i.e. has the tendency to
stretch. It could be White or yellow. It occurs in bronchitis and
pneumonia).
c. Purulent: - This consist pus as in some cases lung abscess or tuberculosis.
d. Muco – Purulent: - This consist pus and mucoid. It is seen in the resolving
state of an acute or chronic infection of the respiratory system.
e. Haemoptysis: - This is coughing up blood. The blood is bright red and
frothy. It is most common in pulmonary tuberculosis, bronchiectasis,
carcinoma of the bronchus, rupture of an aortic aneurysm.
f. Foetid Sputum: - This is very offensive material which is expectorated in
gangrene of the lungs, Advance bronchiectasis and tuberculosis with
cavity formation. It allowed to stand in a glass container, it will separate
in three layers. The upper layer is frothy, the middle layer is turbid, and
the bottom layer a deposit of pus and shreds of tissue.
NB: When a sputum specimen is required for a laboratory test, a sterile
container is used to collect it and it should be collected in the morning before
the patient washes the mouth or takes anything orally.
Cough: - This is caused by irritation of the upper respiratory tracks. The nurse
should observe the type of cough, whether it is dry or moist, accompanied by
pain or spasm, whether it is aggravated by movement on the part of the
patient.
Hiccough: - This is irritation and spams of the diaphragm; It indicates that
something is pressing against the diaphragm. It should be noted whether it is
continuous or intermittent. Continuous hiccoughing is a serious sign and
should be reported at once.
Oedema: - This is swelling due to the accumulation of fluid in the tissues. The
skin at the site of the Oedema pits on pressure, the mark is visible for a few
seconds. Oedema of the lower extremities (pedal Oedema) occurs in cases of
injury, anaemia, renal conditions and heart conditions. Generalised oedema
with dyspnoea is due to renal conditions. Oedema also occurs in pregnancy,
reaction to blood or certain drugs and foods.
Behaviour: - This is often an indication of the patient’s condition. Irritability
and depression may be the result of physical or mental maladjustment. The
over-cheerful or extremely quite patient may also be reacting to some
problem, particularly if such behaviour is unusual. Any change in the normal
behaviour should be noted and reported.

CARE OF THE MOUTH

The mouth is lined with mucous membranes, which secrete mucus to keep the
inside of the mouth and lips moist. In very ill patients, the mucous membranes
become dry and may crack giving rise to sores inside the mouth called
SORDES. When the sores occur outside the mouth, they are called HERPES.
Care of the mouth is done using:
1. The Brush and Paste Method
2. The Mouth Tray Method
INDICATIONS FOR CARING FOR THE MOUTH
To keep the mouth fresh and clean
To stimulate the oral mucous and keep it moist
To prevent infection and dental decay
To prevent mouth odour (Halitosis)
COMPLICATIONS OF A NEGLECTED MOUTH
1. Sordes and Herpes
2. Halitosis (i.e. smell mouth)
3. Nausea and anorexia
4. Inflammation of the mucosa of the following parts:
a. The tongue (i.e. Glossitis)
b. The gum (i.e. Gingivitis)
c. The tonsils (tonsillitis)
d. The larynx (laryngitis)
e. The sinuses (sinusitis)
f. The stomach (gastritis)
g. The Whole mouth (stomatitis)
THE BRUSH AND PASTE METHOD
If the patient is able to sit up, he should be supported in a comfortable
position with a cape mackintosh and towel round his neck to protect his
clothes and linen. He needs a tooth-glass or metal mug containing water of
preferred temperature, toothbrush and paste in a mug, large receiver or basin
and a refreshing mouthwash.
If the patient cannot sit up, he should be placed in a lateral position with the
mackintosh and towel spread under his head and neck. The receiver is
conveniently placed on the towel for him to spit into. If he cannot raise his
head sufficiently to use a tooth-glass, then an angled drinking tube should be
provided. The state of mouth and tongue should be noted.
TYPES OF PERSONS WHO NEED MOUTH TRAY
1. Unconscious patients
2. Severely ill patients
3. Patients with cancer or disease or injury of the mouth
4. Paralysed patients
5. Patients with difficulty breathing has to use their mouths
(severe cardiac or respiratory conditions)
6. Patients who takes little or nothing by mouth
7. Patients with very high temperature (their mouth tends
to dry)
REQUIREMENTS FOR MOUTH TRAY
1. Small bowl with swabs
2. A receiver with spatula or tongue depressor, tongue forceps, mouth gag
(for unconscious patient)
3. Receiver with pair of artery forceps dissecting forceps
4. Small mackintosh or cape mackintosh and towel
5. Gallipots with bicarbonate of soda dilute hydrogen peroxide for
dissolving and cleaning the crust in the mouth
6. Gallipots with glyco thymoline or oraldene or any other suitable
antiseptic for rinsing and freshens the mouth.
7. Gallipots with glycerine in borax or glycerine and honey or glycerine and
lemon to lubricate and sweeten the mouth (NB glycerine should always
be diluted before used in the mouth)
8. Orange stick or tooth pick to remove food particle (e.g. pieces of meat
ropes from mangoes)
9. Receiver for soiled swabs
NB: The NaHCO3 can be substituted with salt and water.
The glycothymoline can be substituted with lime and water.
The glycerine can be substituted with honey or lemon or Vaseline
METHOD FOR USING THE MOUTH TRAY
If conscious, inform and reassure the patient
Screen the bed and turn off the fan
Take the proper tray to the bed side
Position the patient comfortable either on his side or in the upright position
Place the mackintosh and towel under his head or around his neck
Wash your hands
If unconscious use the mouth gag to open the mouth and if necessary use the
tongue forceps to hold the tongue
Using the artery forceps to hold the swabs, it is first dipped in the sodium
bicarbonate to clean the mouth thoroughly, then the glycothymoline is used
to rinse the mouth, and lastly the glycerine in borax is used to lubricate the
mouth
The dissecting forceps is used to remove the used swabs from the artery
forceps and place in the receiver for soiled swabs
The cleaning is done in the following order, the upper cheek, the outer cheek,
the upper inner cheek and the tongue
The orange stick is used to remove food particle from between teeth.
If there are sores and cracks in the mouth, then a smoothing cream or
Vaseline is applied
At the end of the procedure the instruments are washed and packed and
patient made comfortable.
CARE OF THE DENTURES
If conscious and able the patient should be allowed to clean his dentures
himself with toothbrush and paste (or sodium bicarbonate), rinsed well under
running water, it then fixed back into the mouth or placed in a mug of water
and antiseptic. If the patient is severely ill or unconscious it is the duty of the
nurse to take care of the patient’s denture. She then removes the denture
from the patient’s mouth using gloved hand or gauze, scrubbed with brush
and paste or sodium bicarbonate, rinsed well and then placed in a mug of
diluted disinfectant or re-fixed in the patient’s mouth
In the process of cleaning any loose denture noticed should be reported so
that the patient can see the dentist
Patients are never allowed to sleep with their dentures; they should be
removed, scrubbed, rinsed and placed in mug of diluted antiseptic.

ADMINISTRATION OF MEDCINE (DRUGS)

Medicines: are substances obtained from plants, animals and minerals sources
and are used for:
1. The prevention of diseases
2. The cure of diseases
3. The relief of pain
4. Diagnostic purposes
Medicines may be:
1. Solid as in pills, capsules, tablets or powder
2. Liquid as in solution, oils, emulsion, infusion or tinctures
 A tincture is a drug form in which the active ingredient is dissolved in
alcohol
 An emulsion is a mixture in which oil is suspended in water by mucilage
(i.e. mucilage is a solution of gum in water).
 A solution is a liquid in which a substance is dissolved in water
ROUTES OF ADMINISTRATION OF MEDCINES
Medicines can be given by the following routes:
1. ORAL ROUTE: the drug is given via the mouth in the form of liquids,
tablets capsules, or power.
2. INUCTION: application of drugs through rubbing.
3. INHALATIONS: are drugs given through the nose in the form of gas or
vapour. Eg ether, chloroform, tincture benzoin etc
4. PERENTRAL: drugs given via injections:-
i) Intramuscular (I M),
ii) Intravenous (I V),
iii) Subcutaneous (S C),
vi) Intradermal, ie just under the skin,
v) Intrathecal: ie introduction of drugs into the cerebro spina fluid (CSF)
to the meninges and subarachnoid space.
vi) Intraventricular, ie introduction of medication into the ventricles of
the brain by neurologist
5. TOPICALLY: in the ear, nose and eye as drops or ointments.
6. RECTALLY: in the form of suppository or enema.
7. THROUGH THE VIRGINA in the form of pessaries.
8. THROUGH THE RECTUM This is a common route of drug administration
especially for children eg Sedatives and analgesics, barium enema for
diagnostic purposes
9. SUBLINGUAL: Some drugs can be given under the tongue to be absorbed
slowly into the body.
In the treatment of diseases and conditions drugs play an important role,
hence they are written out in prescription sheets.
Prescription sheets: these vary slightly from hospital to hospital but follow a
common pattern.
The prescription sheet must state clearly:
1. The name, age and hospital of the patient
2. The approved name of the drug
3. The dose in metric units
4. The date of prescription
5. The route of administration
6. Frequency
7. The doctor’s signature.
TIME FOR THE ADMINISTRATION OF MEDICINES
 1. If a drug is ordered tds with no other direction, it is given immediately
after main meals of the day (i.e. breakfast, lunch, dinner) or if an
antibiotic, 8hly preferably 6am-2pm-10pm.
2. The medicine ordered AC (i.e. before meals) is given 15-20 minutes
before a meal.
3. The medicine ordered (bd) is given after breakfast and dinner or if an
antibiotic 12 hly.
4. When the medicine is ordered qid (I.e. 6 hly special instructions
regarding waking up the patient should be obtain.
5. Slow acting purgatives are given at night and quick acting purgatives in
the early morning.
6. If a drug is ordered qd the drug should be given once a day in the
morning preferably.
7. If the Dr. wrote st. (start) the drug should be given only once.
THE FIVE RIGHTS IN DRUG THERAPY
1. The right patient
2. The right drug
3. The right time
4. The right dose
5. The right route
These are checked before, during and after the administration of drugs.

ADMISTRACTION OF LIQUID MEDICINES

REQUIREMENTS
1. Lockable trolley with all necessary medicines
2. Bowl with warm soapy water
3. Medicine measure and medicines spoons
4. Saucers or trays
5. Tissues or towels
6. Jug of water or fruit juice ( or preferably the patient’s own drinking
water)
METHODS OR RULES
At the patient bedside
 1. Read the prescription sheet carefully, select the correct medicine and
read the label, cross-checking with the prescription.
2. Ensure that the medicine has not already been given by checking the
treatment sheet and question the patient
3. Using your right hand holding the bottle with the label against your palm
and the index finger holding the cork, shake by inversing slowly several
times.
4. Using the last finger of your left hand remove the cork from the bottle.
5. Without putting the cork down, pick up the medicine measure at eye
level pour out the require dosage.
6. Replace the bottle top.
7. Place the medicine measure on the saucer.
8. Once more check the patient name, the prescription, the bottle label and
the dosage in the medicine measure.
9. Carry the medicine to the patient and stay at the bed side until it is
swallowed (if it is too thick stir with a glass rod or the medicine spoon).
10. Offer water or fruit juice to the patient
11. Record the administration on the treatment sheet
NB
1. All medicines must be kept locked when not in use.
2. Medicine once poured out must not be poured back into the bottle but
discarded.
3. Never leave the medicine on the patient’s bed locker
4. Before replacing medicine bottles after use, the label should be wiped
clean
5. Never administer an unlabelled medicine
6. If medicine contains a DDA or schedule drug, a second trained nurse
should cross check the dosage and administration.
7. Use straw to avoid tarring the teeth and tongue when administering iron
liquids.
ADMISTRATION OF TABLETS, PILLS AND CAPSULS
Follow steps one and two as above
1. Using the last left finger, open the container tip the required number
into a spoon which is placed on a Saucer.
2. Replace the bottle top
3. Crosschecks the patients name, prescription sheet and label of the bottle
 4. Give the tablets or pills or capsules with a glass of water or fruit juice and
ensure checking inside the mouth to see if patient has swallowed all the
medicine.
5. Record the administration on the treatment sheet
NB- powders are placed on the tongue and washed with a drink or water or
juice
Tablets and pills could be crush either between two spoons or with pestle and
mortar
INUCTION/SKIN MEDICATION- the area is washed with soap and hot water
rinsed and dried. This removes dirt and grease and brings the blood to the skin
surface. The medication is then massage into the skin using the palm in a
circular motion until all the medication is dissolved.
INHALATIONS-They may be either in the form of vapour or liquid, which
vaporizes easily, or a fine spray (aerosol spray). They are used for the
treatment of respiratory disease but can also be employed to introduce drugs
into the body, which act on other system of the body. They are used for:
1. The relief of spasms of the bronchial tube as in asthma
2. The treatment of inflammation of the upper respiratory tract
3. Introducing antiseptic into the lungs in the treatment of bronchiectasis
4. Loosening secretion and to relieve pain to coughing
5. Anaesthetizing patients
6. Introducing drugs into the body which act on other systems e.g. to relive
pain due to angina pectoris, the drug is an ampoule which is breaking
into a guaze swab and held to the patient’s nose to be inhaled.
BY VAGINAL ROUTE:- these drugs are called pessaries. This procedure is
usually done by patient herself because she might be too shy if it is done by
someone else.
Before the insertion of the pessary the patient is advised to douch her vagina
with antiseptic. When the pessary is inserted the patient should lie flat on her
back with the buttocks elevated on a pillow or the foot of the bed elevated for
at least one hour. Preferably, it is inserted last thing at night when the patient
is going to sleep.
During treatment sexual intercourse should be forbidden
Examples are canesten, Nyastatin, and stovasol.
After insertion a sanitary pad is applied
ADMINISTRATION OF INJECTIONS
An injection is introduction of a drug into the body via parenteral
routes .i.e. IM, IV, Hypodermic, Intrathecal etc.
PARENTRAL- is the act of giving medication by the use of syringes and needles.
This is an aseptic technique (i.e. a route other than the alimentary tract,
neither the mouth nor rectum is used)
INTRAMUSCULAR (IM) INJECTIONS this is given deep into muscles. The
muscles usually used are those of the buttocks (gluteal muscles) and upper
arm (deltoid muscles).
Drugs in vials or ampoules, Prescription sheet, If necessary ampoule of water
and File

METHOD- I M: This method is used when large amounts are required to be

injected than can be given by hypodermic injection. It is also chosen when the
drug would be irritating if injected superficially.
This is an aseptic technique and strict sterility should be observed.
The hands washed thoroughly. The syringe is attached to the needle,
which should remain in its plastic sheeth. If a vial with a rubber diaphragm is
used this is injected into the vial to facilitate easy withdrawal of the contents.
The required amount is drawn with the syringe at eye level. The needle is
withdrawal and covered with plastic sheeth. At this point the needle may not
be changed. The prescription sheet and the tray are taken to the bedside and
the procedure explained to the patient. The bed is then screened. The site is
then selected i.e. either the buttocks or the arm or thigh. Before injection the
air must be expelled into a swab.
At this point the five rights are re-checked (Right Patient, Right drug,
Right time, Right dose and Right route) and the patient is asked if he had
eaten. If the buttock is chosen, it is exposed and then divided into four
quadrants with a swab. The upper outer most quadrant is then swabed with a
Mediswab in preparation for the injection. The syringe is held at right-angle to
the skin and the needle inserted deep into the muscle. Before inserting the
needle, the skin is swabbed cleaned and then stretch with the finger of the left
hand.
 Care should be taken not to puncture a blood vessel or the periosteum
before injecting the drug; the plunger of the syringe should be withdrawn
slightly to ensure that needle does not puncture a blood vessel. The injection
is given slowly whilst observing the facial expression of the patient. On
removing needle, the area is massaged gently with a swab to encourage
absorption
When preparing injections, particularly antibiotics care must be taken
not to spill the drug on the hands otherwise gloves should be worn to prevent
allergy or dermatitis.
When using glass ampoules, the contents are shaken below the neck
and the top of the bottle snapped off. Most ampoules do not require the use
of files as they are marked.
Before snapping off the top, it should be covered with a cotton wool
swab to prevent injury to the hands.
HYPODERMIC INJECTION-these are given into the subcutaneous tissue.
They are given when-
1. It is desired that the drug should act quickly
2. When only a small volume of fluid is to be injected (1ml or less)
3. When the solution is not likely to damage the superficial tissue
If the superficial blood supply is depleted, absorption is likely to be slow and
uncertain.

REQUIREMENT- They are the same as for an IM injection except that a small
needle is used (No 15 .i.e. blue needle)
The site is selected (i.e. the deltoid muscle or the lateral aspect of the thigh)
and rubbed gently but firmly with a spirit swab in order to clean the skin and
to increase the blood supply. Take up a fold of skin free from veins with the
thumb and fore finger pulling the skin firmly taut. The needle is inserted
quickly and firmly into the fold of SC tissue with the syringe at 45 degree.
An alternative method is to stretch the skin over the site of the
injection with the thumb and forefinger before inserting the needle. This is
often less painful and is particularly useful in obese patient where a fold of
skin is difficult to grasp. The skin is then released, aspirate and then push
slowly, press on the skin with swab while the needle is been withdrawn and
then gently massage to ensure absorption of the drug.
INTERAVENOUS INJECTIONS- (I V) this method of introducing drug or fluids
into the circulation is under taken by the doctor but it is the responsibility of
the nurse for the preparation of the equipment, the support of the patient
during the procedure and the care of the patient after the procedure. The
usual reasons for using this routes are-
1. When a very quick action is require as an emergency.
2. When the drug used will be irritating to the tissues if given
intramuscularly or hypodermal
3. When large amount of drug is to be administered e.g. injections, blood
and other fluids.
4. When it is desired to introduce a drug into the circulation for diagnostic
purpose e.g. radio opaque media used in x ray examination such as
pyelography (x ray of the kidneys, ureters and bladder following an
injection of a radio opaque substance and angiography (procedure done
to view blood vessels). However, with the availability of MRI, dye for
these procedures is no longer needed.
5. When it is desire to produce local clotting in the treatment of varicose
vein.
6. It is also used for the administration of anaesthetic e.g. Large superficial
veins in front of the elbow, the fore arm and the back of the hand
The site is usually one of the large superficial veins in the elbow, the fore arm
and the back of the hand
REQUIREMENT-
Tray with
1. Sterile needles
2. Mackintosh and towel
3. Mediswabs
4. Sterile syringes of appropriate sizes
5. Tourniquet or sphygmomanometer.
6. Roller bandage or guaze dressing for sealing the puncture
7. Receiver for soiled swabs
8. Prescription sheet
9. The prescribed drug
METHOD-
After the preparation of the requirements, it is the nurse duty to inform the
patient about the procedure to screen the bed. At the bed side she selects the
site, apply the tourniquet or the cuff of the sphygmomanometer. The
mackintosh and towel are placed under the arm; the skin for the injection is
cleaned with the Mediswab. The patient is given the ball or roller bandage to
grip firmly. The nurse also study’s the patient arm while the injection is being
given. At this point the doctor makes the vine-puncture after which the
tourniquet is released.
The injection is given by the doctor very slowly lasting for 15-20 minutes.
After the injection and the needle have been removed, cotton wool or gauze
and plaster are applied.

DANGERS WHEN GIVEN INJECTIONS

1. Abscesses: this occurs when the injection is given at the wrong site or
the site is not properly massage or strict aseptic technique is not used or
the injection is not inserted deeply enough.
2. Infections e. g. Hepatitis if I P C is not strictly observed.
3. Paralysis: this occurs when the sciatic nerve is punctured
4. Damaging of the periosteum of the bone especially in very thin patient
INTERAVENOUS INFUSION
An intravenous infusion is the introduction of a prescribed sterile fluid directly
into the blood circulation through the veins.
Replacement of the large amount of fluid or the correction of electrolyte
imbalance is most rapidly and accurately dealt with by the introduction of a
suitable solution directly into the venous circulation. Examples of IV solution
are: sodium chloride, glucose, dilutes plasma, ringers lactate or Darrow’s
solution, blood etc.
REQUIREMETN FOR INTERVENOUS INFUSION
Tray with:
1. Prescriped intravenous fluid
2. Drip or infusion stand
 3. Recipient set or proviset or intrafix in blood transfusion.
4. Assorted cannulae
5. Adhesive strapping
6. Splint, if necessary
7. Mediswab
8. Tourniquet or sphygmomanometer
9. Mackintosh and towel
10. Prescription sheet and fluid chart
11. Angle poise lamp
12. Shaving equipment if necessary
SITES FOR INTERVANOUS INFLUSION
1. The back of the hand 5. In difficult cases the femoral vein
2. The anterior aspect of the elbow 6. The scalp for infants and young
children
3. The forearm 7. The feet and lower leg
4. The arm
A venous cut down is done in severe case of collapse and in case of burns and
in case of tissue loss.
METHOD- it is the doctor’s duty to do the actual venepuncture
1. the hands are wash and requirements assembled
2. The patient informed and the bed screened
3. The tray is taken to the bed side
4. the plastic is removed from the intrafix
5. The control is closed and the protective cap removes from the end closer
to the chamber of the intrafix. The expose end is used to pierce the drip
at the appropriate area.
6. The chamber is squeezed 2-3 times to half-fill it
7. The control is opened slowly to allow the drip to run through the intrafix
thus expelling the air
8. When this has been achieved the other end of the intrafix is kept
covered until the doctor has performed the venepuncture.
9. The site is selected, the mackintosh and towel applied, the tourniquet
applied, the site clean with Mediswab and the venepuncture done.
10. After the venepuncture, the free end of the intrafix is attached to
the cannula, the rate of flow regulated and the set strapped at the site
11. The fluid balance chart is filled with the necessary details
 12. The patient is left comfortable with his locker within easy reach of
his free hand
13. The fingers and site of the venepuncture should be watched
regularly for colour, temperature and swelling (tissuing and infection).
14. If necessary the arm may be splinted
STORAGE OF DRUGS
1. drugs should be stored in locked cupboard away from the patient and
keys kept by the sister or nurse in charge
2. drugs for internal use should be kept separately from those for external
use or reagents
3. Medicines should be stored in cool dry place with a suitable temperature
and away from sunlight this is to maintain the potency or efficacy of the
drug. Some drug should be kept in refrigerators (e.g. insulin, vaccines,
heparin) to maintain their potency. This is called the cold chain.
4. Medicines for storage should be properly labelled
5. Drugs should not be transferred from their original container to an other
6. Once the cupboard is open, it should not be left unguarded.
1. ANAESTHETIC- this could be general(e.g Ether, Chloroform, Nitrous
oxide, Penthothal, Ketamine) which produces complete loss of
consciousness or Local which produces loss sensation in the area in
which they are applied or spinal which produces loss of sensation and
movement from the point of application downwards.
2. ANALGESICS-these are drug which relived pain e.g. Panadol,
paracetamol, Brufen, Tramadol, Novalgin/analgin, Morphine, Pethidine,
Aspirin.
3. ANTIBIOTICS- these are substance prepared from certain living moulds
fungi which prevent the growth and multiplication of bacterial e.g.
Penicillin, Streptomycin, Chloramphenicol, and Amoxycline.
4. ANTIPYRECTICS- they are used to reduce fever e.g. Aspirin, panadol,
Novalgin
5. ANTI-COAGULANTS-these are used to prevent blood from clotting inside
the body by thinning the blood e.g. Aspirin, Drugs Didevan, Heparin
6. ANTIDOTES- are drugs used to counteract the effect of poisons eg
adrenalin, Dexamethazone etc.
7. APERIENTS/PURGATIVES- are drug which produce bowel action e.g.
Cascara, Dulcolax, Senokot.
8. DIURETICS- are used to increase the urinary output by their action on
the kidneys e.g. Lasix, Moduretic.
9. EMETICS – Induce vomiting and includes salt in water, mustard in water.
Emetics are rarely used in recent times instead gastric larvage which is
usually safer to empty the stomach is used.
10. ANTI-EMETICS – These are used to stop vomiting and they include
Phenergan, Primperan, Largactil.
11. EXPECTORANTS – Are used to stimulate the coughing up of mucus
from the lungs e.g. Menthodex, Benylin, Actiifed, Gees linctus.
12. HYPNOTICS – Are drugs which induce sleep but have no effect on
pain.
13. NARCOTICS – Produce very deep sleep during which pain is not felt
e.g. Pethidine, Morphine, Omnopon, Pentazocine or Fortyn.
14. SEDATIVES – Lessen excitements and reduces activities and calm the
patient but they do not always produce sleep e.g. Valium, Codein,
Phenobarbitone, Mogadon.
15. TRANQUILIZERS – Are used for the relief of anxiety and disturbed
mental state e.g. Largactil, Paraldehyde.
16. ANTIHELMENTHICS – These drugs are used to expel worms from the
intestine e.g. Mebendazole (vermox), Albendazole (zentel), Combatrin,
Alcopar, Yeomesan, Antipar (piperazine citrate)

DRUGS CONTROLLED BY THE DANGEROUS DRUGS ACT

 The Dangerous Drugs Act aims at checking the illicit use of drugs liable to
cause addiction i.e. habit forming drugs. The Act controls the sale and use
of these drugs of addiction. These drugs include:
1. Morphine
2. Medical Opium
3. Heroin
4. Cocaine
5. Pethidine
6. Methadone
7. Phenadoxone
8. Levorphanol
Drugs containing these substances may be supplied to the public only on
the written prescription of a recognized Medical Practitioner or Dentist. A
register is required to keep a record of all purchases of these drugs, and the
amount issued to individual patients.
Hospital wards and departments are however authorized to keep a stock of
certain preparations e.g. morphine and Pethidine. The use of these drugs is
under strict control though variation in details may occur in different
institutions.
1. A special cupboard is used for storing such drugs and this is marked DDA.
The usual practice is to have a drug cupboard for schedule 1 drugs with
an inner cupboard fitted with a separate lock and key for DDA drugs i.e. a
cupboard inside a cupboard. It should be noted that all drugs controlled
by the DDA are also listed in the schedule drugs.
2. The cupboard is kept locked and key carried on the person of the SRN in
charged.
3. Renewal of supplies can only be obtained by an order signed by a
medical officer and they can only be given under such written
instruction.
4. Each dose administered must be entered in a special register with the
patient’s name, date and time of giving. The person giving and
crosschecking the drug must sign this entry.
5. DDA drugs register book are checked at regular intervals.
6. If by mistake they are broken, the broken bottle must be kept and the
sample shown to authority concern.
It is a rule that each dose given is checked by two persons one of which must
be an SRN. The bottle from the prescription checked. The hospital pharmacist
checks at interval the contents of the DDA cupboard and compares it with the
register.

THE POISONS ACT

The poison and pharmacy Act controls the sale, prescription and use of
substances, which are potentially toxic or dangerous. There are sixteen
schedule under this act of which only schedule 1 and 4 are concern with
medicines.
In hospital they are kept under lock and the key distinctively labelled.
They are stored in bottles of special shapes.
SCHEDULED 1: These are especially restricted. They may only be sold to
persons known to the chemist, on a medical prescription, or on the police
order. The poisons’ book must be signed. They include:
1. Apomorphine
2. Arsenic
3. Belladoma
4. Carbachol
5. Codein
6. Digitalis
7. Ergot
8. Emetine
9. Hyoschine
10. Strynine
11. methypentynol.
SCHEDULED IV: These substances are sold by retail only upon the prescription
of a medical officer. They are also included in the schedule 1. The group is
divided into scheduled IV A and IV B. Schedule IV A has similar rules to DDA.
EXAMPLES OF SCHEDULE IV A
1.Mostly Barbiturates 2. Gallamine injections (synthetic muscle relaxants)
3. Mustine injection (cytotoxic drugs) 4. Cyclophamide (cytotoxic drugs)
Mercaptopurine (it prevent nuclic acid synthesis, it is used to treat acute
leukaemia in children. With lukaemia the origin is unknown; there is increased
number of WBC).
EXAMPLES OF SCHEDULE IV B
1. Amphetamine- (synthetic drug which stimulate the higher nerve centers,
thereby increasing alertness and abolished fatigue)
2. Chlorpromazine or largactil 3. Milder sedatives 4. Tranquilisers
5. Sulphonamide drugs 6. Thiazide diuretics 7. Thyroid
preparations

THERAPEUTIC SUBSTANCES ACT

This act controls the manufacture, supply and sale of certain drugs and
substance capable of causing danger to the health of the community if used
without proper safeguards. The provision of this is similar to those controlling
the poisons schedule. They include:
1. Antibiotics
2. Blood
3. Heparin
4. Insulin
5. Surgical ligatures
6. Vaccines and sera
7. Curare (used to produce complete muscle relaxation)
8. Corticosteroids and corticotrophin (hormones produced by the adrenal
glands or their synthetic Substitutes.

COMMON ABBREVATIONS USED IN NURSING

ABBREVATION MEANING ABBREVATION MEANING
AC Before meals Syr Syrup
PC After meals C With
Bd/Bid Twice a day In situ In place
Tid/tds Thrice a day O Unit 500mls
Qid/qds Four times a day
Floz Fluid ounce
Ad lib Give freely Pv Per vagina
Aqua/H2O Water Mm Millimeter
qd Four hourly 1/7, 1 day,
2/7 2 day
Nocte At night Mane In the morning
Prn When necessary Stat At once/now
Ung Ointment SOS If necessary and
only once
Ss Half Mist Mixture
Pr Per rectum Pulv Powder
4/52, 4 weeks,
7/52 7 weeks
2/12 2 months

URINE
URINE: - This is the fluid excreted by the kidneys. It consists of waste products
of protein digestion dissolved in water. It is clear and amber in colour, slightly
acidic with the characteristics of ammonic odour. An adult passes about
1500mls per day whilst a child passes about 900mls per day.
Abnormal urine may appear cloudy or contain deposits like pus, blood
mucus, phosphate or urates. The nurse must inspect all urine before disposal
and report on any abnormalities. It must be measured and recorded when
required.
SPECIAL TERMS
VOIDING OR MICTURITION – This is the passing of urine from the urinary
bladder naturally.
FREQUENCY OF MICTURITION – This is the frequent passing of small amounts
of urine
INCONTINENCE OF URINE – This is the inability to retain urine or the
involuntary passing of urine due to weakness of urethral sphincter or damage
to the nervous pathway supplying the sphincter.
RETENTION OF URINE – This is the inability to pass urine even though the
bladder is full thereby causing abdominal distension and pain.
RETENTION WITH OVERFLOW – The patient is unable to pass urine hence the
bladder becomes so full that it drips out through the urethra.
SUPPRESSION OF URINE – This is failure of the kidney to function effectively in
the production of urine. Hence waste matter meant to be excreted is retained
in the system thereby poisoning the patient.
ENURESIS – This is the involuntary passing of urine during sleep due to
weakness of the urethral sphincter or some psychological problem.
DYSURIA – This is painful or difficult micturition.
OLIGURIA – This is the passing of small amount of urine.
POLYURIA – This is the passing of large amount of urine.
HAEMATURIA – This is passing of blood in the urine due to injury or calculi or
malignancy (Cancer).

COLLECTION OF URINE SPECIMEN

To collect a specimen of urine, the patient is given a clean bedpan or urinal or
receiver first thing in the morning. The urine is poured into a clean or sterile
glass/plastic container, labelled with the name of the patient, the ward, age,
date and time of collection.
The specimen could be Midstream Specimen of Urine (MSU), Catheter
Specimen of Urine (CSU) or 24 hours specimen of urine.
MSU (midstream specimen of urine) the genital area is washed thoroughly
with soap and water or antiseptic. The patient asked to micturate in the
bedpan or urinal for a short while. He then continues to micturate in a sterile
receiver or urinal. The urine in the sterile urinal or bed pan is poured into a
sterile lab container which is properly labelled and taken to the lab with the
lab form.
CSU (catheter specimen of urine) this specimen is obtained under sterile
conditions. The urine is drawn from the bladder through the catheter, placed
in a sterile container properly labelled and sent to the lab with the lab form.
For a patient already catheterised, the flow of urine through the catheter is
interrupted, the catheter disconnected from the urine bag and the specimen
obtained.
24 HOURS SPECIMEN OF URINE – Urine passed for the whole 24 hours period
may be needed to
1. Estimate the total volume of urine
2. Test for mycobacterium and tuberculosis
3. Test for urine chemicals
All members of staff and relatives and the patients are informed about this
procedure. The specimen need not be sterile. All urine passed for the 24 hours
period is collected in a special container called Winchester Bottle labelled with
the patient’s name, date and time of commencement, the bottle is placed in a
corner of the sluice room.
At 8 am the patient is asked to empty his bladder and the urine discarded.
Thereafter all urine passed till 8 am the next morning is poured into the
Winchester Bottle, the last specimen is taken at 8am prompt.

CATHETHERISATION
This is the introduction of a special tube made of rubber, metal or gum-plastic
into the urinary bladder via the urethra for the purpose of removal of urine or
the instilling of fluid into the bladder.
The tube used is called a catheter and the most type is the Foley’s Catheter.
When the catheter is to be left in the bladder for continuous urine drainage, a
self-retaining or in-dwelling catheter is used which has a balloon at the end
that is inflated to prevent displacement.
REASONS OR INDICATIONS FOR CATHETERISATION
 1. To relieve retention of urine
2. To assist patients incontinent of urine (e.g. paraplegic or unconscious
patients)
3. To irrigate the bladder
4. To instil cytotoxic drugs into the bladder (e.g. in the treatment of
malignancy)
5. Before major pelvic or abdominal surgery
6. To obtain specimen for diagnostic purpose
7. To ascertain the amount of residual urine i.e. the urine left in the bladder
after voiding.
Catheterisation must be done using strict aseptic technique as there is the
risk of introducing infection into the urinary tract.
REQUIREMENTS FOR CATHETERISATION
Top shelf of trolley: -
1. Three dressing towels or one aperture towel
2. Sterile receiver for urine
3. Receiver with dressing forceps
4. Bowl with swabs
5. Galipot for cleansing lotion
Bottom shelf of trolley: -
1. Sterile gloves (sizes 7 or 8 )
2. Cleansing lotion
3. Appropriate catheter and urine bag with holder
4. Syringe and ampoules of sterile water
5. Mackintosh and towel
6. Adhesive strapping
7. Face mask
8. Lubricant (KY jelly or Vaseline)
METHOD FOR CATHETERISATION
The genital should be washed thoroughly before the procedure is
commenced.
1. Prepare the trolley in a sterile manner
2. Inform the patient screen the bed and turn off all fans close nearby
windows
 3. Turn down the top bedclothes, cover the shoulders and position the
patient (dorsal for females and recumbent for male)
4. Put the mackintosh and towel under the buttocks
5. Wash the hands thoroughly dry with towel and put on the gloves
6. The genital is swabbed with antiseptic lotion in a downward direction
using each swab only once, a swab left covering orifice to prevent
contamination.
7. Place a sterile towel over each thigh, one over the abdomen and one on
the bed in front of the genital area.
8. The sterile receiver is placed between the thighs.
9. The catheter is picked up and lubricated without touching the top half.
10. The catheter is pushed through the urethra for about 10-12 inches
for males and 3-4 inches for females or until the urine starts flowing out.
11. After the flow has started, the balloon is inflated with sterile water
using syringe.
12. The urine bag is then connected to the catheter.
13. The patient is made comfortable and left to rest.
14. All the articles used are taken to the sluice room, washed and placed
in their respective places.
NB: - If a catheter specimen is required for testing, the first few millilitres
are discarded; then using a forceps the end of the catheter is passed over a
sterile container. While the bladder is being emptied, the nurse’s hand should
rest firmly over the lower abdomen to control the collapsing bladder; this
lessens the feeling of shock the patient may experience. With a grossly
distended bladder the urine is released slowly to prevent shock. Record and
report the amount and nature of the urine.
COMPLICATIONS OF CATHETERISATION
1. Infection of part or the whole of the urinary track
2. Trauma and bleeding of the urethra due to poor technique or severe
stricture
3. Shock, if the bladder is emptied too rapidly.
TYPES OF URINARY CATHETERS
1. Foley’s
2. Silver
3.Tiemans
4. Whistle Tip
 5. Bourgie

CARE OF INDWELLING CATHETER

1. The vulva or penis is cleaned twice a day (i.e. morning and evening) with
an antiseptic
2. Check the vulva or urethral orifice for pus or any discharges whilst
cleaning
3. Regular check the catheter or tubing of the bag to ensure proper
drainage.
4. On removing the catheter, it is checked to ensure that it is complete
especially the ballon region
5. Patient with catheter or lying in one place should be turned from side to
side regularly to prevent urine sediments settling in one place except if it
is not possible
6. Patients with catheters should be given plenty of fluids.
a. To prevent concentrated urine
b. To irrigate the bladder (this is to reduce the risk of renal calculi)
7. Always maintain a fluid balance chart.
URINE TESTING AND ROUTINE EXAMINATION
This is an important nurse’s duty. The urine of all new patients
must be tested on admission.
Routine test are done before all operations, for diagnostic purposes and to
estimate any change in the patient’s condition.

In routine examination of urine the following should be noted:

1. Colour
2. Odour
3. Amount
4. Sediments
5. Specific gravity
6. Reaction
COLOUR-Urine is normally clear and amber in colour. Alteration in the colour
may be due to concentration, blood, bile, dyes of certain drugs.
ODOUR
a. An ammonical smell is due to decomposition (on standing, area
is converted to carbonate of ammonia by bacteria)
b. Acetone gives a sweetish odour compared with new monhay
c. A fishy or renkish smell is due to infection by the bacterium coli.
AMOUNT-an adult passes 1100-1500mls of urine daily whereas a child passes
350mls daily. But this may vary depending on the weather condition and the
fluid intake.
SEDIMENTS-normal urine may show sediments on cooling due to
decomposition of urates and phosphates. An abnormal deposit makes the
urine appear cloudy and includes blood, mucus and emission.
SPECIFIC GRAVITY-this is the density of urine compares to that of water which
is taken as 1000. The SG of urine ranges from 1015-1025. This is measured by
a urinometer which should be allowed to float freely. The finger is read from
the scale on the instrument taken the lower level of the meniscus. A high SG
indicates concentrated urine and urine with sugar. A low SG is a dilute urine
indicating inability of the kidneys to concentrate the urine or too much fluid
intake.
REACTION-normal urine is slightly acidic and turns blue litmus paper red.
More accurate PH is done in the lab. Alkalinic urine is found in cystitis, stale
urine, vegetarians, in patients on alkali drugs.
TEST FOR GLUCOSE
1. BENEDITS TEST- an inch of Benedict’s solution is placed in a test tube and
8 drops of urine added. The mixture is boiled for two minutes and allowed
to cool. A precipitate which may be greenish-yellow, yellow or orange will
appear if glucose is present. Any precipitate after 15 minutes should be
ignored. (Benedict’s solution is a solution of No2, Co2, CUSO4 and sodium
be citrate)
2. CLINI TEST-this is the most accurate test provided the tables have not
expired. It is used for diabetic patients. Place 5 drops of urine in a clean
test tube using a pipette or dropper, rinse the dropper and pipette. Add 10
drops of water into the test tube. Drop the clinitest tablet into the test
tube without touching the tablet. 15 minutes later after boiling activity
ceases shake the test tube gently and compare the colour change with the
provided colour chart. The colour ranges from blue to orange.
 3. CLINISTICKS TEST-the reagent strip is dipped in a test tube of urine and
read after 60 seconds. If glucose is present this turns blue within 60
seconds. If there is no colour change then no glucose is present.
TEST FOR PROTEIN (Albumin)
1. THE HOT TEST – fill two-third of the test tube with urine and boil the top
inch over a flame, holding the tube near the bottom with a holder. Move
the tube round constantly to prevent breakage. A cloud appears on
boiling which may be due to protein or phosphates. This is seen when
examined against a dark background add a few drops of acetic acid. If
the cloud disappears it is due to phosphates but if it persists or becomes
denser, protein or albumin is present.
2. THE ANES ALBUSTIX TEST – The strip is dipped in the urine and removed
immediately. No colour change indicates no protein but if there is
protein present, a green or greenish blue colour develops at once.
Comparison with the colour scale provided shows the amount of protein
present. Protein in the urine (Albuminuria) occurs in renal diseases and
sometimes in pregnancy.
TEST FOR KETONES-the acetest table method is the most accurate and
convenient test for acetone and diacetic acid. Place a tablet on a clean white
surface such as white paper or white tile. Add one drop of urine and note the
colour after 30 seconds. If the tablet remains cream then the test is negative.
In a positive test, the tablet change colour which vary from pale lavender to a
strong mauve.
Test for acetone, ketones and sugar are done when there is suspected
diabetes mellitus or disease of the pancreas.
TEST FOR BILE
1. IODINE TEST- half fills the tube with urine and add a few drops of 10%
iodine solution. A green ring indicates the presence of bile. Bile in the
urine indicates diseases of the liver, bile duct and gall bladder, and
obstructive jaundice.
2. ICTO TEST TABLETS-place 5 drops of urine on the test mat provided
and put 1 icotest tablet in the center of the moist area. Place 2 drops
of water on the tablet and waits for 30 seconds. If bile is present the
test mat around the tablet will turn bluish purple with30 seconds. If
there is no colour change or if it turns faints red or orange the test is
negative.
TEST FOR BLOOD-urine with blood is called haematuria but only when present
in large quantity can be seen with the naked eyes.
1. HAEMASTIX TEST-the urine is stirred and the test end of the haemastix
dipped into the urine. It is removed immediately after 30 seconds. It is
compare with the chart provided; if there is no blood, there will be no
colour change. After 30 seconds any colour change will be ignored.
2. OCCULT TEST- the drop of urine specimen is placed in the centre of the
test paper and the tablet placed in the centre of the moist area. Two
drops of water are then added to the tablet. If positive the diffused area
of blue appears on the paper around the tablet in two minutes.
Haematuria is indicative of disease or injury to the genitor-urinary
track.
BLADDER WASHOUT OR IRRIGATION-the bladder may be washed out to
prevent the formation of blood clots after operation on the bladder the
prostate gland or as treatment for the mucous membrane lining the bladder
as in case s of chronic cystitis. A bladder syringe is usually found to be
satisfactory as the pressure of the irrigating fluid is easily controlled and good
suction obtained. This is a sterile procedure.
Alternatively the continuous irrigation will be using a three way
catheter.
INTAKE AND OUTPUT OR FLUID BALANCE CHART
In certain illness it is important to keep a strict record of the quantity of the
fluid taken and that excreted by the patient. All fluids taken orally, rectally,
intravenously, via nasogastric drip or via nasogastric tube are measured and
recorded in one column of the chart as intake. All fluids excreted such as
urine, vomits, watery stool, or aspirated via nasogastric tube are recorded in
the other column as output. At the end of 24 hours period (i.e. 6am-6am or
8am-8am) the two columns are added separately and the balance of fluid
obtained by deducting the output from the intake. (The balance might be
positive or negative) the total intake should exceed the output by about
900mls. If the output is greater than the intake there is danger of dehydration.
The balance of the day is added to the balance of the previous day to get the
grand balance.
Fluids are also loss during respiration and perspiration. This cannot be
measured and is known as insensible loss, it is estimated as 1000mls daily.
INDICATIONS FOR FLUID BALANCE CHART
 1. It serves as a guide in the treatment of dehydration (as in diarrhoea,
vomiting, excessive sweating, poor absorption of tube feeding)
2. To assess the effectiveness of treatment of oedema.
3. To keep a careful record in the case of kidney failure.
4. A patient receiving IV infusion, blood transfusion must have a fluid
balance chart.
5. Patient on regular nasogastric aspiration and continuous catheterisation
or supra-pubic cystomy.
6. Patient with renal disease or conditions.
UNCONSCIOUSNESS
This condition in which the patient is not aware of his/her surrounding
because there is depression in the cerebral functioning, it ranges from stupor
to coma. It may be transient (i.e. fainting or syncope) or it may be long lasting.
Stupor is semi or partial unconsciousness in which the patient can be
aroused.
Coma is a profound or deep or completed state of unconsciousness
where the patient cannot be aroused.
In unconsciousness, the normal reflexes (i.e. swallowing, sneezing, coughing,
and winking) that protect the conscious person are absent. These protective
functions must be taken over by the nurse until the patient can fully be
himself/herself.
CAUSES OF UNCONSCIOUSNESS
1. Alteration in the blood supply to the brain resulting in cerebral anoxia
/hypoxia e.g. fainting, asphyxia.
2. Gross damage to the brain tissue by injury, e.g. fracture of the skull,
Cardio Vascular Accident (CVA), subarachnoid haemorrhage, cerebral
tumour, cerebral concussion, etc.
3. Inflammation of the brain which can be due to (e.g. meningitis, brain
abscess, encephalitis, cerebral malaria, septicaemia)
4. Epilepsy
5. Drugs: e.g. alcohol, anaesthetics, opium, carbon monoxide and hypnotic
drugs.
6. General metabolic disturbances producing a toxic effect on the brain
(e.g. uraemia, eclampsia, diabetic coma, hypoglycaemia, renal failure
hepatic coma, etc
 7. Shock due to injury, electric shock, hypovolumic shock, neurogenic
shock etc.
Interference with the gaseous exchange in the respiratory system is important
because inadequate O2 and too much Co2 cause cerebral oedema which
pushes the patient into a deep state of unconscious and fatality.
SIGNS AND SYMPTOMS OF UNCONSCIOUSNESS
There are two major threats to the life of the patient
1. The disease or condition that causes the unconsciousness
2. The unconscious state itself
i. The patient is unaware of his/her surroundings
ii. The protective reflexes are absent,
iii. Little or no response to stimuli,
iv. The eyes do not respond to light,
v. the temperature is either subnormal or high and the pulse rate is
altered,
vi. Blood pressure could fluctuate not reaching normal.
vii. Respiration is slow and sometimes noisy.
NURSING CARE OF AN UNCONSCIOUS PATIENT
1. Position the patient in the semi-prone or lateral, or dorsal position with
the head turned well to one side. This helps to
(a)Establish and maintain a clear airway
(b) Prevent the tongue from falling back
(c)Drain secretion which can be aspirated thereby interfering with
gaseous exchange.
2. The vital signs must be monitored. Initial baseline vital signs must first be
taken monitored half hourly or hourly until they become stable. Any
fluctuation must be reported to the in charge and doctor. Temperature
should be taken rectally.
3. Suction is done to remove mucus as the swallowing; coughing and
sneezing reflexes are absent.
4. Oxygen may be given
5. Monitored the level of consciousness by using the glasco-coma scale. This
indicates whether the patient is improving or deteriorating. Restlessness
may mean the patient is coming out of the unconscious state or going
deeper into coma or there is a distended bladder or the patient is choking
or there is reduced oxygen in the brain.
 6. Maintain a strict fluid balance chart.
When giving IV fluid do not run it too fast except the patient is
severely dehydrated. The normal rate of flow is between 40-60 drops per
minute and between 2000-3000mls daily depending on the amount of NG
tube feeding.
7. Observe the bladder and catheterize with an indwelling catheter. In males
swing the penis to one side and then tape.
8. An NG tube or Ryles tube is passed to aspirate to avoid paralytic ileus and
also to feed the patient and administer drugs. Before feeding aspirate if
there is more than 50mls of aspirate then there is a tendency for paralytic
ileus to occur. Feeding is done 1-3 hly with about 300mls-500mls of food.
9. Medications are given as ordered through the NG tube or by injections
NB: sedatives are not given and if muscle relaxants are given only give
sparingly.
10. Do mouth care to prevent complications of a neglected mouth.
11. Do pressure areas and turn patient from side to side every four hours to
prevent bedsores and minimize the risk of hypostatic pneumonia.
12. Keep the skin clean and dry (bed bathing and powdering)
13. Passive exercise to prevent deformity and deep vein thrombosis.
14. Remove denture if any.
15. Do eye toilet.

GLASGOW COMA SCALE

GLASGOW COMA SCALE: Do it this way

RATE
For factors interfering with communication, ability to respond and other
injuries
Eye opening, content of speech and movements of right and left sides
Sound: spoken or shouted request Physical: Pressure on finger tip,
trapezius or supraorbital notch
Assign according to highest response observed
CRITERION OBSERVED RATING SCORE
 Eye opening
Verbal response
Best motor response

CROSS INFECTION
This is the transfer of pathogenic micro-organisms (found in the wards
from place to place, or from person to person, or from one infected article to
another article. These micro-organisms are found in: -
a. The dust and air
b. The nose and mouth of nurses, patients and relatives
c. Toilet articles and other equipment’s in common use in the wards
d. Trolleys, trays and other accessories used in the wards
e. Unsterile dressings and instruments
f. The hands especially long nails, nail varnish and rings. The hands must
be regarded with suspicion at all times. Certain bacteria are present
 even on the cleanest skin and nails; hence nails should be short, the
hands washed before and after every procedure.
g. Cuts, scratches, boils, infected eyes, sore throats and common cold
should be reported before undertaking any sterile procedure.
PREVENTION OF CROSS INFECTION
INFECTION PREVENTION AND CONTROL (IPC)
The ward
1. Bed-making and cleaning should be done at least an hour before
dressing is done, preferably it is better if dressing can be done in a
separate room
2. All sputum-mugs, vomit-bowls, bedpans and urinals must be taken to the
sluice room, well washed and disinfected.
3. The sterilizing room and dressing trolleys should be washed and moped
thoroughly
4. The sterilizer should be emptied, washed, filled with fresh water and put
to boil daily
5. All instruments should be washed thoroughly under running tap with
soap and brush before boiling
6. Dressing drums, instruments and dressing are never placed on the floor
because bacteria in the dust or air will contaminate them.
7. Mattresses, bedsteads and pillows should be disinfected, cleaned and
placed in the sun after discharge or death of a patient especially those
with communicable diseases.
8. No nurse, relative or another patient should sit on a patient’s bed.
THE NURSE
1. Nurses must be clean neat and tidy with clean uniforms and comfortable
shoes.
2. No jewellery, wristwatch, nail varnish or long nails should be worn whilst
doing a procedure.
3. The hands should be washed before and after any procedure especially
after handling bedpans, urinals, sputum-mugs and vomit-bowls.
4. A nurse with cuts or boils on the hands, infected eyes, sore throat or
common cold should not be allowed to do dressings or sterile
procedures.
 5. To reduce the risk of droplet infection, there should be no unnecessary
talking from the nurses or the patient whilst dressing is being done
especially directly over the wound.
THE PATIENT
1. The hands should be washed after using the toilet
2. Bedpans, urinals, sputum-mugs and vomit-bowls must be washed with
soap, dried and kept in their proper place.
3. Patients are not allowed to sit on another patient’s bed. They are not
allowed to eat with their hands or eat with other patients together in
the same plate. Communal eating must be discouraged.
4. The patient should be advised not to play with their dressing.
5. Clean wounds are dressed first and dirty or septic wounds last.
6. A wound must not be uncovered until everything is ready for dressing.
THE VISITORS
1. Visitors are not allowed in the ward during sterile procedures.
2. They should not be allowed to sit on the patient’s bed.
3. They should not be allowed to eat with patients’
4. They should not look or touch any patients dressing.
WARD DRESSING PROCEDURE
All sterile dressings are done using the Non-Touch or Aseptic
Technique. This is a method use to prevent the contamination of wounds by
ensuring that only sterile objects and fluids come in contact with the wound
site. Forceps are used as a second pair of hands when cleaning and dressing
the wound. Two nurses are responsible to do dressing, one to act as dresser or
sterile nurse and the other to act as assistant or dirty or unsterile nurse.
THE BASIC DRESSING TROLLEY
The trolley is washed with soapy water using a small towel or rag,
starting from top to bottom including the rails and sides. The wheels are
cleaned for at least once a week; it is oiled to give a free movement. The top
shelf is completely sterile, when laying it, strict aseptic technique is used. The
bottom shelf carries all unsterile equipment’s needed. The hands should be
washed before cleaning the trolley, and before the top shelf is laid out. After
setting up the trolley it is wheeled to the bedside holding only the sides and
then the hands are scrubbed for at least two minutes. A facemask may be
worn before setting up the trolley.
The Bottom Shelf
After cleaning the trolley, the bottom shelf is set first with the following:
1. Tray with bottles of lotion needed, bandages, strapping, safety pins,
penicillin gauze, scissors, gentian violet etc depending to the need.
2. Receiver for soiled or used bandages.
3. Receiver, dry or with disinfectant for used instruments.
4. Bowl or receiver for used dressings, salvage container
5. Mackintosh and towel
The Top Shelf
After setting up the bottom shelf, the hands are washed before setting the
top shelf. It contains: -
1. A covered instrument tray or two receivers one covering the other with:-
a. 1 to two pairs of dissecting forceps
b. 2-4 pairs of artery or dressing forceps
c. Stitch removing scissors (to remove stitches) or Clip-removing forceps
d. Probe
e. Sinus forceps
f. Surgical scissors
2. Bowl with swabs and gauze dressings
3. Two gallipots, one for cleansing lotion and the other for healing lotion.
NB: The dressings are properly assessed before being placed in the bowl.
4-6 inches forceps are preferably used for dressing.
DUTIES OF THE DRESSERʼS ASSISTANT
She/he works as instructed by the sterile nurse and these instructions are as
follows: -
1. In very simple language, she explains the procedure to the patient.
2. Offers the patient a bed pan or urinal.
3. If necessary, she closes nearby windows, put off fans and screens the
bed.
4. She prepares the patient by positioning the patient comfortably, turning
down the linen exposing only the area which is to be dressed.
5. She puts the mackintosh and towel underneath the area to be dressed.
6. She loosens the strapping or bandage which holds the dressing but the
dressing is not removed.
 7. She brings the soiled dressing bin to the bedside.
8. She washes her hands and may assist the dresser to bring the trolley to
the bedside after it has been laid up.
9. When the trolley is at the bedside, under the instruction of the dresser,
the lotions are poured into the gallipots with the label against the palm.
10. During the dressing, she reassures the patient and gives support to the
part being dressed.
11. She assists in applying the strapping or bandage after the dressing have
been done.
12. At the end of the dressing, she makes the patient comfortable,
unscreened the bed, opens the windows, removes and washes the
mackintosh and towel, and then empty the soiled bin

DUTIES OF THE DRESSER

Generally, the duty of the dresser is to make sure that the sterilizing
room is properly cleaned; instruments and equipment’s are washed
thoroughly and placed in the sterilizer with the water completely covering
them. After initial boiling, the dresser scrubs her hands under running water
with soap and brush; and starts to set the trolley in the following manner: -
1. The trolley is cleaned with soap and rag from top to bottom not
forgetting sides and rails.
2. The bottom shelf is then set up
3. The hands are again scrubbed and the top shelf is then set up
4. With the aid of the assistant, the trolley is taken to the bedside
5. The dresser returns to the sterilizing room and scrubs her hands
properly for 3 minutes starting from the fingers, the palms, the nails,
to the elbows.
6. The hands are dried using a sterile towel or shake well with the hands
above the elbows (drips of water falling from the hands on sterile
instruments or wounds causes contamination)
7. At this point she does not touch anything except the instruments she
uses for dressing or the gloves she wears for dressing.
8. She instructs the Assistant to pour the lotions (cleansing and healing)
into the gallipots.
 9. She may or may not wear gloves depending on the type of dressing
being done or the health status of the patient.
10. One hand should always remain as clean hand and the other hand
as working hand. Careful handling of the forceps should be maintained
at all times to avoid contamination.
OBSERVATIONS MADE DURING DRESSING
1. Observe whether the wound is healing by first, second or third intention
2. Observe for inflammation around the wound
3. Observe for haematoma
4. Observe for bleeding
5. Observe for pus or slough formation.

PROCEDURE DURING THE DRESSING

After the lotion has been poured by the Assistant and the soiled-dressing bin
positioned: -
1. The Dresser picks up the dissecting-forceps, remove the soiled dressing,
examine the dressing before depositing it in the bin; she then deposits the
dissecting forceps in the kidney dish underneath the trolley.
2. She then picks up two artery or dressing forceps, one in each hand; the
right to act as working hand for right-handers.
3. She uses the sterile hand to pick up a swab, gently dip it in the cleansing
lotion before passing it to the working hand
4. The inside of the wound is cleaned first from top to bottom; using one
swab once and then discarded.
5. The Sister or Charge-Nurse should be called to examined and observe the
wound progress.
6. After the inside and the outside of the wound has been cleaned and dried,
the forceps are discarded in the receiver provided underneath the trolley
and a new set picked up to handle the dressing.
7. The dressing is dipped in the dressing lotion with no excess and the wound
packed with it. With the aid of the Assistant, strapping or bandage is
applied.
8. The mackintosh and towel are removed from underneath the patient, the
patient made comfortable, fans turned on, screens removed, windows
opened and the patient left comfortable.
9. The instruments and equipment are washed with soap and brush under
running tap; not forgetting the grooves in the blades and the handles. They
are then placed in the sterilizer completely immersed in the water and left
to boil.
10. The mackintosh is washed and hung to dry; and the towel sent to the
laundry.
11. The soiled dressing bin is emptied and washed.
NB: - Before the commencement of the dressing, sterile towels may be placed
round the wound.

BASIC PRINCIPLES OF ASEPTIC TECHNIQUE

1. Aseptic technique is carried out in the operation theatre, delivery rooms,
changing of dressings, catheterisations, administration of injections, chest
aspirations, abdominal tapping, lumbar puncture, vaginal examinations,
and administration of IV fluids.
2. Sterile objects must be kept only with other sterile objects. Unsterile
objects should never come in contact with sterile object; if that happens
the previously sterile object will be contaminated and so must be
discarded.
3. Objects that are out of vision or below the waist level or the back of the
nurse are considered as being unsterile; do not give your back to the
trolley.
4. As contamination by airborne sources are easy, therefore the
environment must be clean; there should be no talking over the exposed
wound, a nurse with a respiratory infection or sore-eye should not be
involved in any aseptic technique; reduce activity during dressing (i.e. no
sweeping fans or movement of personnel).
5. As fluids flow downwards; then wet forceps are held with tips down; after
washing the hands, they should be held above the elbows; care must be
taken not to touch the edge of the container with the tips of the forceps
when removing them from the disinfectant; dry wounds are considered as
 clean wounds and suppurating or sloughy wounds are contaminated or
infected or dirty wounds.
6. Sterile forceps are held above and in front of the waist with the tips held
downwards.
7. When pouring lotions, the bottles should not touch the container into
which it is being poured.

STERILIZATION: It is the process by which instruments and surgical equipment

are rendered free from micro organisms
METHODS OF STERILIZATION
1. BAKING:- This is a method of sterilization by dry heat. Hot air is
circulated in specially constructed ovens. A temperature of about 160
centigrade or 320 Fahrenheit for one hour kills all micro-organisms and
their spores. This method is suitable for delicate eye instruments, glass
syringes, knife blades, skin grafting knives. The instruments or items to
be sterilized are thoroughly washed and dried before being placed in the
oven.
2. Boiling: - Though water at boiling point can kill all non-spore forming
bacteria in two minutes; spores cannot be destroyed by this method.
Hence boiling in ward boilers or sterilizers is open to abuse. This is
because the articles at times are not completely cleaned or immersed
and the sterilizing time may have been interrupted by the immersion of
contaminated objects, thus interfering with the sterilization process.
The articles for sterilization should be properly washed and completely
immersed so that the water covers and come in contact with all surfaces.
Boiling should be for at least 10 minutes (and longer for contaminated
articles) after the water; it retards rusting and alkaline; its lethal effect is
increased. Therefore sodium carbonate could be added to the water; it
retards rusting and reduces blunting if sharp instruments during boiling.
In case where contamination with spores forming organisms (such as
anthrax or tetanus) is suspected boiling should be repeated.
There are three types of boiling:-
I Initial Boiling: - This is done before the commencement of the dressing
round or procedure and it last for about 30-60 minutes
 ii Subsequent Boiling: - This is done in between the procedure or dressing
and last for about 10-20minutes.
Iii Terminal Boiling :- This is done at end of the procedure and last for about
5-10 minutes
3 Autoclaving: - This is sterilization by using steam under pressure and is
very effective in destroying organisms and their spores. It is the method
of choice for all linen, cotton article, gowns, and towel, dressing packs,
glass metal and rubber articles, gloves.
The temperature reached inside the autoclave depends on the
vacuum created and the shorter the sterilization time. The load must not be
compact but should be loosely packed so that the steam can penetrate the
articles. The process last for about 20-45 minutes depending on the vacuum
created and the pressure used. The high temperature kills the organisms by
the coagulation of the cell proteins of the organisms.
4 Chemical sterilisation: - This method of sterilisation is achieved but the
use of liquid or gaseous agents known as disinfectants to kill micro-
organisms. Articles to be sterilized are thoroughly cleaned and
completely covered with the disinfectant of the correct strength and left
for the correct time needed for the destruction of the micro-organisms.
The disinfectant must have the power to kill all types of bacteria and
their spores. The presence of organic matter like blood, pus, faeces or
pieces of tissues will prevent effective action of the disinfectant hence
the articles for sterilization must be thoroughly cleaned. It is also
desirable that such chemical agent should not come in contact with the
skin or it will burn the skin and cause deterioration of the wound healing.
Chemical sterilization is now les widely used. Disinfectants are more
effective when hot than when cold and they act more rapidly in acidic
medium than alkaline medium. Some common disinfectants are formalin
chloride and its compound, Hibitane 1%, Lysol, usol, chlorine and
carbolic solution. These chemicals must be changed regularly. When the
 instruments are removed, they should be rinsed in sterile water before
being used on the skin to prevent burning of the skin.

The method is used mainly for sharp instruments like scissors and blades but
can be used for almost all other articles.

5 Gaseous agents like ethylene oxide and formaldehyde can also be used
for the sterilization of rooms and large objects; this method of
sterilization is known as FUMIGATION.

PRE AND POST OPERATIVECARE

PREOPERATIVE CARE

This is defined as the physical and psychological preparation of a patient

before surgery; it is when the decision for surgery is made and ends when the
patient is taken to the theatre operation bed.
Except in exceptional extreme emergencies or day cases, all surgical cases
should be admitted 2 or 3 days prior to surgery so that they become adjusted
and familiarise themselves to the ward routine and the necessary
investigations can be done.

Careful pre-operative care greatly influences the successful outcome of the

operation and prevents post-operative complications.

Mental and physical rest are necessary prior to a major surgery.

Pre-operative investigations include chest-x-rays, urine test (for albumin,

glucose, blood, and acetone), and blood test (for HB, WBC, MP, ESR, Clotting
time). Also the anaesthetist or house surgeon examines the patient’s chest for
any tendency to bronchitis, a recent cold or influenza or pneumonia, or
cardiomegaly, the patient’s drinking and smoking habits.

The patient should be encouraged to take sufficient nourishment with first

class proteins and vitamins A, B and C with enough fluids and glucose.
Depending on the patient condition intravenous fluids may be given.

The consent form for surgery and the administration of anaesthetic should be
signed by the patient if conscious, rational and above 18 years of age; or by a
close relative or close friend and witnessed by a nursing staff.

In the case of a female patient, coloured nail varnish and lipstick should be
removed as artificial colour on the lips or nails may mimic cyanosis during
anaesthetic.

Cleanliness of the skin is of paramount importance i.e. good personal hygiene.

Safeguards should be taken to obviate the risk of an operation being

performed on a wrong patient or the wrong limb, hence an identification label
is attached to the patient; giving his full name, hospital number, ward,
diagnosis, type of surgery and the surgeon.

PRE-OPERATIVE CARE (THE DAY BEFORE SURGERY)

MENTAL PREPARATION: - Most people are nervous of undergoing surgery,

some are frightened. Fear and nervousness before surgery is detrimental
unless reassurance is given. The nurse must instil confidence in the patient by
explaining in very simple terms what is expected during and after the surgery.
A calm and cheerful manner will help patient dispel any feelings of
apprehension. The patient must have a very good night s rest, hence a
sedative may be ordered to be given.

PHYSICAL PREPARATION: - The skin over the site of the operation is shaved
and washed. A specimen of urine is collected and tested for glucose, protein
and acetone. The patient is starve from 10 pm. Enema saponis may be given at
10 pm and rectal washout in the morning if surgery is in the rectum.

The patient must have a bed or big bath in the morning of the surgery.

SKIN PREPARATION: - For abdominal surgery, the area is shaved, the patient
bath on the day of the surgery.
For bone surgery, the preparation is done for three successive days, the skin is
shave, wash patient with betadin or cetrimide or hibitane or surgical spirit and
then bandaged. This sequence is carried out for three successive days.
For surgery on the scrotum, it is shaved, scrubbed lightly with soap brush on
the day of the surgery.
ROUTINE PREPARATION ON THE DAY OF THE SURGERY
No food is given within six hours of surgery (fatty foods are withheld for
at least 12 hours prior to surgery). The patient is given a bath (either a bed
bath or in the bathroom, preferably a shower) in the morning of the day of the
surgery. Continue reassuring the patient. One hour before the patient is taken
to the theatre, a well labelled theatre gown is given to the patient. The hair is
brushed for males; and for females it is covered with a cap or head-tie or a
triangular bandage. All hair pins, ear-ring, jewellery and dentures are removed
(except for wedding rings), and given to the sister or a trusted relative for safe-
keeping. Make-up and nail varnish should be removed.
The patient is asked to empty the bladder or a self-retaining Foleys catheter is
passed just before any pre-medication is given (i.e. 30-45 minutes before the
scheduled time of surgery). The patient is placed on the theatre trolley or
walks, accompanied to the theatre by a nurse with the case note, consent
form, laboratory investigations, scan results and x-rays. The nurse hands over
the patient and documents to the theatre staff or the anaesthetist.
NB: - Great care must be taken to ensure that the correct patient is taken to
the theatre especially if more than one patient in the ward is due for surgery.
In that respect, the patient gown should be properly labelled stating the
patient’s full name, hospital number, ward, and diagnosis, type of surgery, the
surgeon and the type of anaesthetic to be given.
Vital signs which are taken just before the patient is taken to the theatre
serve as baseline.
PRE-MEDICATION:- A sedative or hypnotic drug is often ordered to be given
the night before surgery to promote a good night’s rest and reduce anxiety;
these drugs include phenergan, valium and largactil.
Certain drugs are also ordered to be given ½-1 hour before surgery and
they may be given for several purposes such as promoting relaxation,
decreasing nasal and salivary secretions, relieving pain and promoting
sedation. These drugs include atropine or scopolamine, pethidine, omnopon,
largactil ;( in recent years fewer pre-medication are ordered except
antibiotics). After the pre-medication has been given, the patient should be
left to rest quietly behind screens under observation until the scheduled time
for surgery. The atropine is given sub cut on the deltoid muscle of the arm
whilst the sedative is given IM on the gluteus muscle.
POST-OPERATIVE CARE
This phase begins when the patient is transferred from the theatre to the
ward or the recovery room. It consists of ensuring that the patient is nursed in
the greatest possible comfort, is kept free from hazards and complications.
When the patient has been taken to the theatre the bed is made. Also at
the bedside are equipments such as oxygen apparatus, suction machine, BP
apparatus, temperature, pulse and Respiration (TPR) tray, drip stand, bed-
blocks and emergency tray.
After surgery, the patient can either be left to recover in the Recovery
room nursed by the theatre staff (especially after a major surgery has been
done or the patient has been under anaesthesia for a long time or the patient
is an elderly patient) or the patient is taken straight to the ward.
On collecting the patient, the nurse makes sure that:-
1. She checks the operation site to ensure that there is no bleeding
 2. She checks the pulse, respiration and BP to ensure that they are there
and within normal rage
3. She checks to see that the patient is alive in a stable condition and
the airway clear.

The patient must be collected by a trained and experienced nurse

who makes sure that the appropriate instructions and operation notes has
been written.
In the ward the patient is placed either in the lateral, semi-prone or
dorsal position depending on the type of anaesthesia used and the type of
surgery done.
If spinal anaesthesia is used, then the patient is laid flat on his back
with no pillows. The foot of the bed may or may not be elevated. The
operation site is observed regularly to ensure that no bleeding occurs. The
vital signs are monitored ½ hrly for the first 4 hrs, then hrly for the next 12 hrs
and then 2 hrly for next 8 hrs after which it is done 4 hrly. The patient is kept
in this position for at least 24 hrs after surgery, except when absolutely
necessary is this position changed; but after 4 hrs the patient should be able to
move his legs; failure to do so should be reported to the Surgeon. The patient
should be able to pass urine after 4 hrs if self retaining urinary catheter is not
in-situ.
Medications and IV infusion should be given as prescribed. The
commencement of feeding depends on
1. The type of surgery done
2. The bowel sounds for abdominal surgery
3. The initiative of the surgeon.
When the patient has fully recovered, he/she should be assisted to
freshen up and the theatre gown changed.
If general anaesthesia (GA) is used and the patient is brought to the
ward unconscious, then he is placed in the lateral or semi-prone position and
nursed as an unconscious patient. But if the nature of the surgery does not
permit turning of the patient on the side, then the patient is placed on his
back with the head turned to one side to maintain a clear air way.
If an endo tracheal tube or rubber airway is left in-situ, it should be removed
when the patient begins to get restless or preferably removed by the patient.
The vital signs are monitored ½ hrly whilst the patient is unconscious and 2
hrly after the patient is fully conscious and stable. If the patient vomits the
mouth is mopped with a swab on a sponge forceps. If the patient is cyanosed
or having difficult breathing, oxygen may be given. The suction machine is
used to remove vomitus, mucus and saliva from the mouth or pharynx
(throat). The dressing should be inspected frequently; if blood or serum soaks
through, a sterile dressing is placed over the soaked dressing without
disturbing the original dressing, and any excessive bleeding after 48 or 72 hrs
must be reported to the surgeon. Clips are removed after 5-7 days and stitches
after 7-10 day’s post-operative. Urinary output is monitored and charted.
Bowel sounds are monitored. The commencement of feeding depends on:-
1. The bowel sounds
2. The type of surgery done
3. The surgeon
Under normal circumstances, except in major abdominal surgeries,
sips of hot fluids are commenced soon after the patient gains consciousness
i.e. about 6-8 hrs post-operatively. Medications and infusions are given as
ordered.
As pain and restlessness exhaust the patient leading to collapse, they should
not be allowed; hence analgesics are ordered to relieve pain.
When the patient is fully conscious he/she is freshen up by washing the face,
mouth rinsed and change the theatre gown. The patient is then nursed in the
position he finds most comfortable (the upright or semi-recumbent position
may be favoured as these positions allow the diaphragm free movement,
consequently better ventilation of the lungs) Mobilisation is commenced at
the earliest possible time (18-48hr); the amount of movement depending on
the type of surgery. If the patient cannot come out of bed immediately then
passive exercises must be done and later active exercises to prevent foot drop,
stiffness and thrombosis. Deep breathing exercises will prevent stagnation of
secretions and will aid venous return. It also promotes peristalsis, thus
preventing abdominal distension and constipation.
Early ambulation the next morning should be encouraged to prevent
hypostatic pneumonia and deep vein thrombosis.
The time the patient is confined to bed depends on his general condition and
on the nature of his surgery. Specific nursing care is given depending on the
nature of the surgery and complication that might occur.
 BARRIER NURSING
This is a method of nursing a patient with an infectious disease in
isolation; either in a separate room or behind screens.
It helps in the prevention of the spread of the infectious or contagious
disease to other people. Every person coming in contact with the patient must
observe certain rules.
Gowns, gloves and in some instances mask and head cover must be
worn by all personnel entering the room or the nursing area.
Damp dusting and vacuuming should be done to prevent infected dust
from rising into air. All articles used by the patient must be kept separately,
labelled and sterilised immediately after used.
Disposable items should be disinfected, sealed in plastic bags and disposed off
according to the hospital policy.
Charts, X-rays and other documents should never be taken into the
room or area of nursing.
In severe gastro-intestinal infection, faeces and other contaminated
excretions may have to be covered with strong disinfectant for one or two
hours before being disposed off according to the hospital policy.
 A Barrier Nursing sign must be placed outside the door or the screens.
Remove all non-essential furniture. There should be wash hand basin with a
suitable antiseptic solution e.g (soap, chlorine) and paper towels within the
enclosure. The patient’s personal property and nursing equipment’s should be
at a minimum. Gowns are worn and kept inside the enclosure. After use, the
gowns are suspended on hangers with the inside being protected against
contamination.
On recovery after various tests have been carried out and the patient is
free from infection, Terminal Disinfection must be done.
DISINFECTION: - This is the process of rendering an area or room or article
free from micro-organism by the use of chemical and physical agents
There are two types of disinfection namely: - Current disinfection and
Terminal disinfection.
Current Disinfection: - Is the measure carried out to prevent the spread of
infection while a patient is suffering from an infectious condition. Great
importance is attached to Current Disinfection as it is considered that by the
time the patient recovers, there is little infection left in the area.
Terminal Disinfection: - Is the fumigation of a room, and all equipment used
by an infectious patient after the patient has been proven non-infectious (i.e.
has recovered) and moved elsewhere (i.e. out of isolation).
All disposable equipments are fumigated, placed in an incinerator and
burnt.
Non-disposable equipment’s are fumigated, washed and sterilised by either
boiling or soaking in a chemical or placed in the sun. Furniture, the walls and
the floor are fumigated with formaldehyde gas (all equipment’s for fumigation
are spread out, and the doors and windows sealed whilst fumigation is being
done). After 12 – 18 hr the room is thoroughly aired and then washed with
soapy water from top to bottom.
ARTIFICIAL FEEDING
Artificial feeding is done when food cannot be taken orally.
Indications for artificial feeding: -
1. Unconsciousness
2. Shock
3. Diseases causing paralysis or obstruction of upper digestive tract
4. In cases where swallowing is difficult or impossible.
5. After operation on the mouth or pharynx or larynx
This is done via a Nasogastric or Gastrostomy tube. The feeds should contain
the maximum amount of nourishment in the fluid form. Feeds are given at 38
degrees centigrade. Strict oral hygiene must be observed to prevent mouth
complications.
NASO-GASTRIC INTUBATION: - This is the insertion of a flexible hallow tube
into the stomach via the Nasal route.
Indications for inserting a Naso-gastric tube:
1. To administer nutrients, fluids and drugs to the patient
2. To remove gas or fluid from the stomach and intestines
3. For investigations in pyloric stenosis
4. To test the gastric juices
 5. To aspirate stomach contents in case of paralysis or obstruction of the
intestines or in abdominal operations.
6. To relieve nausea and vomiting as in case of hyperemesis gravidarum.
Contraindication of Nasogastric intubation:
When there is damage or obstruction in the upper part of the digestive tract.
Requirements for Nasogastric intubation
Tray with; -
1. Appropriate size of N-G tube
2. A Gallipot with swabs
3. Vaseline or KY jelly
4. 20 mls syringe
5. Blue litmus paper
6. Receiver for soiled swabs
7. A glass of water.
8. Stethoscope
9. Vomit bowl with cover
10. Small bowl with Luke-warm water
11. Cape mackintosh and towel

METHOD OR PROCEDURE FOR N-G INTUBATION:-

1. The procedure is explained to the patient and the bed is screened.
2. The patient is placed and supported in the upright or semi-recumbent
position if conscious. If the patient cannot sit up, he is placed in the
recumbent position.
3. Mackintosh and towel are arranged round the neck to protect the
pyjamas or night dress.
4. The nostrils are cleaned with swabs or else the patient is asked to blow
his nose on a tissue. It is then checked of patency by asking him to blow
his nose or to sniff with the other nose closed
5. The hands are then washed and sterile gloves put on.
6. Mark the point up to which the tube is to be passed by measuring the
distance on the tube from the nostrils to the ear and down to the navel.
Marked with a strip of plaster.
7. Lubricate the tube for about 15-20 cm with a thin coat of Vaseline or KY
jelly with a swab.
 8. Insert the proximal end of the tube into the nostril, sliding it upwards
and backwards along the floor of the nose. If an obstruction is felt,
withdraw the tube, leave the patient to rest and then re-insert the tube
again.
9. As the tube passes down into the naso-pharynx, ask the patient to sip
water and swallow it. He should be encouraged not to cough as the tube
is being passed.
10. Advance the tube until the plaster mark reaches the point of entry
into the external flares. It is ascertain whether the tube is in the stomach
by :-
a. Placing the stethoscope over the epigastria region and injecting 4-5
mls of air into the tub, the stomach will be heard rumbling
b. Aspirate some gastric contents and test with blue litmus paper, which
will turn red.
c. The distal end of the tube is placed under a small bowl of water: if it
bubbles then it is in the trachea and not the stomach and remove it
immediately.
11. If the tube is in the stomach it is sphygoted and taped to one side
of the face
12. The patient is made comfortable. The bed unscreened and the
equipments washed and packed.

NASO-GASTRIC FEEDING
Requirements on a Tray
- Mug with feed standing in a bowl of Luke-warm water
- Lotion thermometer
- Funnel, or rubber tubing, connector spring clip in a bowl
- 2 pints measure
- Mug with fresh drinking water
- Serviette or small mackintosh and towel
Method for Naso-gastric feeding
1. The patient is informed, the bed is screened
2. The assembled requirements are brought to the bedside
3. The serviette or towel is placed round the neck or under the head
4. The temperature of the feed is checked with thermometer and it should
be 38oc: if there is no thermometer, it is tested with the back of the
hand
5. Air is expelled from the rubber tubing and funnel by running water
through and then attaching the clip
6. The funnel should be held above the level of the patient’ head. The
funnel must not empty or air will enter the stomach causing discomfort.
At the end of the procedure a little water is passed down the tube to
rinse it.
7. At the completion of the feeding the funnel and rubbing are
disconnected and the tub is sphygotted.
8. The feed and water are recorded and the patient left comfortable
9. The apparatus is thoroughly washed, rinsed and either kept for
subsequent feeding or changed for a fresh pack, depending on the
hospital policy.

NASO-GASTRIC ASPIRATION
Aspiration of the stomach contents for the purpose of diagnosis or to
empty the stomach, e.g. in acute abdominal distension or paralytic ileus
may be necessary. The stomach contents are aspirated by attaching a 20 or
60 mls syringe to the end of the tube or alternatively, by using a siphonage
apparatus for continuous drainage.
In case where gastric aspiration is repeated or continuous drainage is
required, IV fluid replacement therapy and fluid balance chart is required
and maintained

GSATRIC LARVAGE/STOMACH WASH OUT

Washing out of the stomach may be necessary in case of
a. Pyloric stenosis,
b. Intestinal obstruction
c. Treatment of poisoning when the poison has been swallowed (e.g.
narcotic and acute alcoholic poisoning)
d. A stomach wash out should only be done in the treatment of poisoning
by a corrosive or caustic substance after the poison has been neutralized.
Requirement on a Tray: -
1. Jacque’s oesophageal tube (18/20 inches for adult), (8/14 inches for
children
2. Large funnel, rubber tubing (3-4 feet long)
3. A connector in a bowl
4. A pint measure
5. Large jug with solution (e.g. tap water or sodium bicarbonate solution I
drachms to I pint of water or 6 pints of normal saline solution which
should be at 100 of or 38oc
6. A large bucket to receive washout water
7. Mouth wash and towel
8. Lubricant
9. If unconscious tongue depressor and gag in a receiver
10. Mackintosh to protect the floor
11. Cape mackintosh to protect the patient’s clothes

METHOD FOR GASTRIC LAVAGE OR WASHOUT

-Inform the patient close nearby windows put off fans and screen the bed
-Bring the requirements to the bedside
-Position the patient if conscious and co-operative the patient is placed in
the upright position with the patient learning slightly forward if
unconscious then the lateral position with the head titled back.
- The bed and the clothes are protected with the mackintosh
-The bucket is placed on the floor at the head side on a mackintosh to
protect the floor
-Wash the hands.
The oesophageal tube is lubricated and passed into the stomach via the
mouth, the patient should be swallowing; THE TUBE SHOULD NOT TOUCH
THE BACK OF THE THROAT
-The pint measure is filled with the solution poured into the funnel and
allowed to flow through the rubber tubing into the stomach
-When the funnel is almost empty it is returned fluid is clear or until the
prescribed amount of fluid is used
-The tub is then lightly compressed and withdrawn quickly
A conscious patient is given a mouth wash and the mouth wiped dry
 The contents of the bucket should be measured to ensure that the amount
of fluid injected into the stomach is returned back: IT IS SAVED FOR
INSPECTION BY THE SISTER AND THE DOCTOR.

In addition –Backrest and bed-blocks

URE FOR ABDOMINAL TAPPING

GASTROSTOMY FEEDING
This method is used when there is obstruction of the oesophagus and no
food can be taken by mouth. An opening is made into the stomach via the
abdominal wall and a self-retaining catheter inserted which is closed with a
spigot.
Through this tube, the patient is fed with liquid foods containing the
maximum nourishment. Feeding is usually done 2-4hrly in the first 48hrs and
then gradually increased.
The area round the wound must be protected with a sterile, oily dressing
because the gastric juices cause severe soreness if it leaks onto the skin.
The tube is taken out periodically and replaced with a new one
REQUIREMENTS FOR GASTROSTOMY FEEDING ON A TRAY
- Receiver with funnel, rubber tubing clip, connector, oesophageal tube
- Pint measure with water
- Mackintosh and towel
- Measure with feed in a bowl of hot water clean dressing and bandage, if
necessary
METHOD FOR GASTROSTOMY FEEDING
As the reason for gastrostomy feeding is a malignant stricture of the
oesophagus, the patient is probably emaciated from months of starvation. It is
important that he should receive a nutritious and well balanced diet. Feeding
commences as soon as patient recovers from the anaesthetic. Any food that
will pass down the tube is given.
The patient is placed in the most comfortable position and the linen
folded down over the lower abdomen. The protective towel is arranged to
protect the dressing. All air must be expelled from the rubber tubing before
feeding by running a little sterile water through. The spigot is removed from
the abdominal tube and the feeding apparatus connected, to it. 30mls of
water is first run through (if this produces no pain or discomfort, then the fluid
is entering the stomach; if there is pain or discomfort the fluid is entering the
peritoneal cavity). If the tube is in the stomach, then the feeding is done. After
the feed, 30mls of water is run into ensure that the tube is clear of
obstruction. If the tube is blocked, a little solution of sodium bicarbonate
should be run in.
The dressing is so arranged that it need not be disturbed during the
feeding but should be done with strict aseptic precautions. Mouth care by
every shift is done to prevent halitosis and other complications of the mouth.
If the gastrostomy tube is permanent, the patient is taught how to self-
administer the feed, how to care for the skin around the wound and how to
clean the equipments.
FEEDING THE PATIENT
Diet is an important factor in the care of the patient it may be ordered by
the doctor of left to the discretion of the nursing staff. The types and amount
of food needed for body building and repair of the tissues depend on the
condition of the patient. Essentially the nurse should know the individual need
of each patient.
Meal times are often the high light of the patient’s day; a welcome
breaks in the monotony of the ward routine, hence it should be made as
comfortable and nice as possible.
No treatment should be carried out during or immediately before a meal
is due. All patients should be made comfortable. The ward should be neat tidy
and well ventilated without draught. Trays, plates, cutleries and glassware
should be immaculately clean. Attention should be given to preparation and
serving of foods, cold foods should be served on cool plates and vice versa.
Servings should be small and attractive (a plate piled high with food will
destroy the appetite); a second serving can be given if required. The menu
should be varied especially those on special diets which tend to be
monotonous because of the limitations of foods allowed. Care must be taken
to serve the correct food to the correct patient and note made of the reaction
to the type and amount of food at each meal. Plenty of time should be
allowed for the meal.
FEEDING OF HELPLESS PATIENTS
Few patients enjoy being fed and sometimes on the slightest
provocation will refuse the food offered, He should be allowed time to eat
properly and not made to feed a nuisance. Nourishment is very important:
progress and rest depends on it. The skilful nurse will ensure that the diet is
taken with pleasure. Successful feeding depends on the ability and attitude of
the nurse who should show no sign of haste or impatience. The patient must
be allowed to chew and swallow without haste. The meal should be
accompanied by cheerful wards to ease the tension. The patient should be
supported in a comfortable position before the food is taken to the bedside.
The nurse should be at the right hand side of the bed facing the patient. Solids
or semi-solids are cut into small pieces in the kitchen. When bringing the food
to the bedside it should be covered on a tray
 Patients on fluids in the recumbent position are fed using a feeding
cup with a spout which must be immaculately clean. To feed the patient the
nurse passes her left arm under the pillow and slightly lifts the head. The
feeding cup is held with the right hand and the fluid allowed to run slowly. The
patient controls the flow by blocking the spout with the tongue
If a spoon is used for giving fluids, the flow is directed to the side of
the mouth and not directly over the tongue onto the back of the throat as this
will cause the patient to choke or cough. Straws can also be used. At the end
of the feeding, the mouth is wiped clean with a napkin and the cockeries taken
to the kitchen to be washed in hot soapy water. Particular attention must be
paid to the spout and the angles inside the feeding cup. If ice is called to be
sucked, they are wrapped in gauze or muslin cloth.

DIETS
These are dependent on the condition of the patient. They could be (1)
Full or normal (2) light (3) Fluid (4) Special.
LIGHT DIET: - This is given in here the full diet is not easily digested or where
bulky meals would be detrimental to the progress of the patient. The diet will
contain foods as milk, eggs, steamed fish, minced meat, soup, pap, agidi
jellies. Extra fluids may be included as light diet.
FULL OR NORMAL DIET: - This is given to patient with good appetites who are
on the way to recovery such a diet will contain all the food factors in well-
balanced proportions
FLUID DIET :- This consists of nourishing fluids the basis of which is often milk
flavoured to taste, soups, fruit juices, eggs beaten in milk, very light pap are all
included is given to patient’s just re-commencing the ingestion of foods as
patients from surgery or serious illness,.
SPECIAL DIET: - They are based on the calorific value of foods (A calorie is a
unit of heat, it is used to judge how much fuel the body needs for the work it
has to do. It is the amount of heat required to raise the temperature of 1kg of
water by 10c
The average calorific requirements for healthy adults are as follows:-
(a)Manual workers doing heavy work=400cal/ day
(b) Moderately heavy workers=300-350 calorie/ day
(c)Sedentary workers- 250-300 calorie/day
Women usually need fewer calories than men.
Foods taken in excess of the calorific needs of the body are stored as fat
The food materials producing heat are fats, carbohydrates, proteins and
alcohol
1gm of carbohydrate gives 4.1 calories
1 gm of protein gives 4.1 calories
1 gm of fat gives 9.3 calories
1 gm of alcohol gives 7.0 calories

The types of special diets are as follows

(1)Reducing diet or low calorie diet
(2)High calorie or fattening diet
(3)Low protein diet
(4)High protein diet
(5)Low salt or salt-free diet
(6)Gastric or low residue diet
(7)Diabetic diet
(8)High residue diet
(9)Low fat diet
(1)Reducing or low calorie diet :- This is devised to satisfy the appetite
while avoiding foods which cause the deposit of fat, so that fat already
stored in the body can be used to provide the energy requirement;
thereby reducing the weight of overweight patients and those suffering
from hypertension, heart failure and osteoarthritis. The calories can be
achieved by using the following foods. Salads without Oil or dressings,
clear or plain soup, fresh fruits, green vegetable (such as cabbages,
beans, spinach, lettuce), marmite.
Foods to be avoided are potatoes, peas, bananas, grapes, figs, dried
fruits, sugar, pastry, cakes, confectionery, jam, honey, chocolate,
marmalade, mayonnaise, bread, beers alcohol patients on reducing diet
should be weighed weekly and in the same clothes. The weight should
be recorded on a chart
(2)High calorie or fattening diet: - This is designed to increase the weight
especially after server illness or for underweight patients. A full general
diet can be taken with the addition of extra milk, carbohydrate, fats and
glucose.
(3)Low protein diet: - This is used for patients with nephritis or from
uraemia. About 40gm of proteins are given per day to lessen the work on
the kidneys. Extra sugars, fruits and vegetables are added.
(4)High protein diet this is given where repair of the body tissues is
essential, as in severe burns, chronic or sub-acute nephritis. Over 100gm
of protein is given daily. The diet should include 2 pints of fresh milk, 56
gm of protein is divided throughout the day There is no restriction on the
amount of carbohydrates, fruits and vegetables consumed protein
supplements like casilan (90% protein), complain (31%protein) and
skimmed milk (34.5% protein) can be used.
(5)Low fat diet: - This is useful in case of jaundice or cholecystitis; fat is
reduced to minimum skimmed milk should be used. The following foods
are allows white fish, lean meat, fresh fruits honey, vegetables, jam,
marmalade. The following should be avoided Butter, margarine, fat
meats, salmon, herrings, fried food, egg yolk, salad cream, cakes
(6)Low salt or salt-free diet: - This may be ordered where there is gross
oedema, in congestive heart failure or hypertension. The food may be
with very little salt, (low-salt) or without salt (salt-free) in the former
case i.e. low salt, the salt content is reduced in the food. This can be
achieved by using low-salt bread and butter, restricting the milk and
protein foods .In the case of salt-free diet, on table salt is allowed and no
salt is used in cooking. For bidden foods include salt-fish, salt-meat,
bacon, chocolate, syrup, kippers, tinned meat and all foods contain
bicarbonates of soda or baking powder
(7)Gastric or low-residue diet: - it contains no roughages to reduce
peristaltic action. It is given to patients with inflammation or ulceration
of the Gastro-in-testinal tract or from diarrhoea. The objective is to
provide sufficient nourishment without stimulating the secretion of
gastric juice. This is achieved by given small quantities of bland or plain,
non-irritating foods frequently thus preventing the stomach from being
empty. Foods allowed are milk, egg, butter, strained fruit juices, minced
meat and fish, sieved vegetables milk given two or three hourly. Foods to
be avoided are fried foods, skins and pips of fruits, seasoned (spicy)
foods, pickles cigarette and alcohol. The food should be well chewed and
slowly swallowed (no hurried eating)
(8)High residue diet: - this is suitable for those suffering from atonic
constipation; the aim is to increase the bulk of the diet to stimulate
peristalsis. It is recommended that a plentiful amount of cereals fruit
with their peels and green vegetable be given.
(9)Diabetic Diet: - The consumption of sugars and carbohydrate is
controlled. The diet varies with age, weight, activities and stage of the
disease, and is compiled by the doctor and the dietician. The nurse is
responsible to serve the correct food. If a mistake is made, the patient
will have serious consequences. A nurse in doubt should ask for guidance
from the ward sister or charge Nurse.

WARD REPORT
 This could be either verbal or written. It is very important aspect of the
nurse’ duty and it is highly technical. It serves to inform the medical and
nursing staff about all that happened in their absences, all that was
observed about the patient and what is planned for the patient.
In writing report, no abbreviations should be used as this may be
misinterpreted and therefore endangering the patient’s life.
The doctor informed and the treatment ordered, and the comment made, the
time that he died, whether or not he was certified as dead and by whom, the
whereabouts of the corpse and what arrangements has been made for the
corpse.
Patients on special treatments:- Reports are written for any patient on special
treatments, such as blood transfusion, Naso-gastric tubes, indwelling
catheters, drainage tubes, rectal larvage, gastric larvage, special X-rays like
barium meal, barium enema, sigmoidoscopy, Endoscopy, Intravenous
pyelogram, chest aspirations, Paracentesis abdominis, enemata etc
GASTRO-ENTERITIS
This is a dangerous infectious disease affecting the G I T and the patient should
be barrier nursed (isolated). Strict I P C measures must be taken when dealing
with patient’s soiled linen and stools. Hospital policy with regards to the
disposal of infected linen and stools must be strictly adhered to.
The chief symptoms and signs are diarrhoea and vomiting, loss of weight,
hyperpyrexia. Exhaustion may occur within 24-48 hrs.
NURSING CARE: - The patient must be kept warm, but tepid sponging may be
necessary when there is hyperthermia. Fluids are given orally, intravenously or
via a naso-gastric drip as prescribed. In severe cases nothing is given by
mouth, the patient is given fluids intravenously to rest the gastro-intestinal
track. The amount of fluids given, the number of stools and vomit and other
fluids excreted are strictly monitored and recorded.
Mouth care is done by every shift. Vital signs are monitored half hrly. or
hourly. Pressure areas are treated 4 hrly or more frequently if the patient
confined to bed. The nurse must take every possible precaution against the
spread of the disease because gastro-enteritis is extremely infectious and its
effects may be disastrous, especially where children and infants are
concerned.
PARALYSIS
 This is the loss of motor function of a limb or a set of muscles (e.g. the
head or the facial muscles or the intestines). There are four types of paralysis
namely: -
1. Monoplegia 2. Hemiplegia 3.Paraplegia 4. Quadriplegia

1. MONOPLEGIA: -This is the paralysis of one limb or one set of muscles. It is

the result of lesion or damage to the motor nerves supplying that limb or
set of muscles.
2. HEMIPLEGIA: -This is the paralysis of one side of the body. It is a result of
lesion or damage to the brain. If the paralysis is on the left side of the
body, then the lesion or damage is on the right side of the brain and vice
versa.
3. PARAPLEGIA: -This is paralysis of the lower part of the body and the limbs.
It is usually the result or injury of the spinal cord. The paralysis starts from
the point of damage or lesion downwards. There may be incontinency of
either faeces or urine or both. If the damage is high level, then there may
be constipation or even interference with the respiratory mechanism
leading gradually to death.
4. QUADRIPLEGIA: -This is paralysis of both the upper and lower limbs as a
result of damage or disease of the whole brain or the upper part of the
spinal cord.
TREATMENT AND NURSING CARE: - This depends on the type of paralysis and
the cause. The nursing care at the onset of the conditions or disease of the
brain will include complete bed rest.

Frequent changing of position to avoid the risk of hypostatic pneumonia,

pressure sores and thrombosis is done. The patient should be kept warm
without overheating. Mouth care should be done at least 4 times a day.
Daily bed bathing is done. Routine treatments of the pressure are done twice
daily. If the patient is incontinent, strict attention should be given to the
pressure areas. If the patient is conscious, a light nourishing diet is given. If the
patient is unconscious, he will have to be fed artificially (i.e. via Naso-gastric
tube or intravenous fluids). The bladder must be monitored for retention or
incontinency of urine, catheterisation may be done. The bowels are also
monitored for constipation or incontinency of faeces. Foot-rest, sand bags and
soft pillows are used to support paralysed legs from dropping or turning
outwards. A soft pillow is placed underneath the ankles and between the
knees to prevent bedsores. A bed-cradle is used to take the weight of the linen
off the limbs. Passive exercises or physiotherapy is commenced as soon as the
patient is well or stable enough so that they do not become bedridden.
MENINGITIS
This is inflammation of the meninges, which are the coverings of the brain
and the spinal cord. They are dura mater, arachnoid mater and the pia mater.
The cause is infection spreading to the brain and spinal cord, by
meningococcal bacteria, fungi and viruses. The patient rapidly becomes very ill
with severe rigor, hyperpyrexia, stiffness of the muscles of the neck and limbs,
mental confusion and irritability. Convulsion may occur especially in children.
There is photophobia also.
NURSING CARE AND TREATMENT: - The drugs of choice are Chloramphenicol,
penicillin, analgesics and sedatives; the dosage depends on the age and body
weight of the patient, and the virulence of the disease.
 The patient should be nursed in a shaded quite room because noise and
light causes irritation leading to convulsions.
 There should always be a nurse at the bedside monitoring the patient
 Bed bathing is done daily
 Changing of position is done 2 – 4 hrly, and routine treatment of
pressure areas twice daily or more often if incontinent.
 Care of the mouth is done at least 4 times daily
 Maintain fluid balance chart
 Intravenous fluid may be required
 Light fluid highly nourishing diet is given orally or via Naso-gastric tube
 Catheterisation may be done
 Visitors are restricted in the acute phase
The diagnosis is confirmed mainly by laboratory investigation on the
cerebro-spinal fluid (CSF) after a lumbar puncture has been done.

LUMBAR PUNCTURE
This is a specific procedure carried out by a doctor to obtain CSF. The
procedure involves the introduction of a special needle (trocha and cannula)
into the lumbar sub-arachnoid space via the lumbar vertebra.
INDICATIONS FOR LUMBAR PUNCTURE
1. For diagnostic purpose; the CSF is sent to the laboratory for analysis; also
radio opaque media is introduced for radiological examination.
2. To estimate the pressure of the CSF by attaching a manometer to the
special needle
3. To introduce drugs into the brain and spinal cord (e.g. spinal anaesthetic,
streptomycin in cases of tuberculosis meningitis)
4. To relieve pressure on the brain in cases of raised intracranial pressure.
CONTRA – INDICATIONS OF LUMBAR PUNCTURE
1. Suspected spinal cord compression
2. Local injection: - If skin infection is present, examination should be
delayed until the problem is resolved
3. Unco-operative patients; lumbar puncture is a potentially hazardous
procedure which requires maximum patient co-operation
4. Severe degenerative spinal joint disease. In such cases difficulty will be
experienced both in positioning the patient and in access between
vertebra.
INVESTIGATIONS DONE ON THE C.S.F.
The Pressure: - This is investigated at the time of the L.P. using a glass
manometer. Normal cerebro-spinal fluid pressure is 60 – 180 mmH2O.
The Colour: - The fluid should be clear and colourless. The first 3 – 4 mls may
be blood-stained due to local trauma on insertion of the needle but it clears as
the procedure continues. However if blood – staining is due to sub-arachnoid
haemorrhage, all samples will be blood-stained.
Blood Cells: - There should be no blood cells except for a few lymphocytes.
The presence of white cells is indicative of meningitis or cerebral abscess.
Monocytes would indicate viral or tuberculosis or encephalitis. The cells are
seen under the microscope.
Culture and Sensitivity: - The presence of micro-organisms would indicate
meningitis or cerebral abscess. By isolating the specific organism the
appropriate antibiotic therapy may be commenced.
Protein: - The total amount of protein in the CSF should be 15.45mg/dl. Raised
globulin levels are indicative of multiple sclerosis, neuro-syphilis, degenerative
cord or brain disease. Raised levels of protein may indicate meningitis,
encephalitis or the presence of a tumour.
Cytology: - CNS tumours tend to shed cells into the CSF where they float
freely. Examination of these cells after L.P will whether the tumour is benign
or malignant
REQUIREMENTS FOR L.P. ON A STERILE TROLLEY
TOP SHELF: -
1. Bowl with sterile dressings
2. Receiver with two dissecting forceps and a pair of scissors
3. Gallipot with cleansing lotion
4. Receiver with a selection of L.P. needles (troche and canula)
5. Manometer in a receiver
6. Specimen bottles (2 or 3).
BOTTOM SHELF: -
1. Local anaesthetic
2. 2mls or 5mls syringe and needles sterile gloves
3. Mask strapping
4. No becutane spray or collodion for sealing the puncture
5. Any drug for injection and the prescription sheet
6. Draw mackintosh and towel
7. Receiver for soiled instruments
8. Receiver for soiled swabs
IN ADDITION
1. Good lighting (anylepoise lamp)
2. Stool or chair for the doctor
3. Bedblock or bed elevator
METHOD OR PROCEDURE FOR LUMBAR PUNCTURE
Usually the procedure is carried out by the doctor. The nurse’s duty is to
prepare the instruments, to support the patient during the procedure, to
assist the doctor during the procedure and to take care for the patient after
the procedure.
- Inform the patient, screen the bed, close nearby doors and windows, and
put off fans
- The patient is placed in the correct position i.e. either lying down in the
left lateral position or in the sitting position with the head bend towards
the knees.
 - If the patient is lying down then the mackintosh and towel are placed
under the buttocks.
- The site (between the 3rd and 4th lumbar spine) is properly cleaned with
antiseptic and swabs and then properly dried.
- The doctor then wears the sterile gloves
- The doctor infiltrates or localised the site with the local anaesthetic
- The doctor selects the correct size of needle he wants.
- With the patient properly positioned (i.e. the knees well flexed towards
the chest and the head bent forward), the doctor makes the puncture
until the needle reaches the sub-arachnoid space.
- At this point, the manometer may be attached to the needle to get the
pressure of the CSF
- The specimen containers are placed under the needle to collect the CSF
for laboratory test.
- When the needle is withdrawn, the puncture site is sealed by applying
the collodion or nobecutane and sterile dressing applied and strapped
over the puncture site.
- The specimen are labelled and taken to the laboratory immediately with
the investigation form.
- After the procedure the patient is observed for the next 24 hrs for
leakage from the puncture site, headache, backache, abnormalities in
the vital signs
- The patient is made comfortable in bed, kept in bed for at least 10 hrs,
encouraged to take at least 2 – 3 litres of fluid daily, the foot of the bed
may be elevated.
- The equipment’s are removed from the bed side and properly cleaned,
the procedure properly recorded in the appropriate notes.

COMPLICATIONS FOR LUMBAR PUNCTURE

1. Headache and backache which may be severe, these are due to the CSF
with drawn (it may persist up to a week until the CSF pressure and
amount normalises itself).
2. Intro of infection into the brain and spinal cord due to poor aseptic
technique
3. Fainting which may lead to collapse
 4. Hypotension
5. Dizziness
CONTENTS OF NORMAL C.S.F.
Amount …………………………………………..130mls
Colour……………………………………………...Clear or colourless
Reaction…………………………………………….alkaline in nature (i.e. it turns red litmus
paper to blue).
Protein……………………………………………….15 to 45 mg/dl
Glucose………………………………………………..45 to 60 gm/ml
Cells……………………………………………………...0 to 10 per ml
Pressure………………………………………………….60 + 180 mm H2O
Specific……………………………………………………..1005
The CSF is produced by the choroid plexus in the lateral ventricles in the
brain. In many respect CSF resembles a dilute form of lymph and contains
glucose, proteins and salts.
It has the following functions: -
1. It acts as a “water cushion” protecting the brain and the spinal cord from
jars and shocks due to body movements.
2. It conveys nutrient to the brain and spinal cord.
3. It removes waste products from the brain and spinal cord.

DIABETES MELLITUS
Special cells in the pancreas known as the beta (β) cells in the islets of
langerhans secrete a substance called insulin, which balances the amount of
sugar in the blood stream. Failure of these cells to function properly results in
diabetes mellitus in which glucose normally stored in the liver and cells as
glycogen accumulates in the blood and eventually appears in the urine.
 Insulin is important in the metabolism of fats and carbohydrates.
Overweight people may develop signs of diabetes during middle age (maturity
onset). Such patient produces insulin but the excess fat prevents the efficient
action of the insulin. In most cases the correct diet will restore the balance of
blood sugar to normal. The diet aims at providing maximum nourishment
without excess sugar. This is achieved by plenty of proteins, vitamins and
green vegetables. Whilst restricting carbohydrates fats.
In young people, diabetes may occur where the islets of langerhans do
not function and no insulin is produced. Insulin has to be introduced artificially
to avoid a very high level of sugar in to blood (hyperglycaemia) and ketosis
(i.e. condition of increased ketones in the blood). Hereditary plays some part
in the incidence of diabetes. It can run through some families.
Diabetes in young people is known as Juvenile onset diabetes
NURSING THE DIABETIC: - The nurse takes an important part in the care and
progress of the diabetic patient being responsible for giving the correct diet,
the correct dosage at the right time of insulin or anti-diabetic drug, the testing
of urine for glucose, daily weighing of the patient, for keeping records of all
treatment and investigations, and for advising and reassuring the patient.
Extreme care must be taken of the skin, in the prevention of bedsores, in the
care of the nails, as broken skin in diabetes is very difficult and very slow to
heal up. In some cases there is loss of feeling, especially of the feet, so that the
patient is unaware of heat, pain or soreness of the skin. When bed-cradles are
in use, they should be so placed so that the feet and toes does not come in
contact with it, for fear of wounds which may be slow to heal up.
Change in the blood sugar level is reflected on the brain, resulting in
confusion, obstinacy, emotional outburst and other abnormal behaviour.
Hence the nurse should show patience and tolerance. These signs gradually
disappear as treatment progresses.
SIGNS AND SYMPTOMS OF DIABETES
- Excessive fatigue or tiredness
- Polyuria i.e. passes a lot of urine (glucose is a solute which needs a
solvent, hence it draws water from the system as a result there is thirst,
dryness of the skin, weakness and itching in the vulva of females)
- Drowsiness after a meal
- Nocturia i.e. passes a lot of urine at night
 - Irritability and confusion
- Blurring of vision (the blood vessels of the eyes are damaged)
- Poor healing of wounds
- Loss of weight and muscle cramps
THE DIABETIC AT HOME
Before being discharged from hospital, the diabetic patient is shown
1. How to test his urine for blood sugar using the clinitest outfit
2. How to self-administer the insulin
3. Where disposable syringes and needles are not available, the patient is
shown how to dismantle, assemble and sterilise the syringe and needle
4. Advised is given as to the care of the hands and feet, and supervision by
a chiropodist
5. The importance of regular dental care should be stressed on.
The diabetic should carry a card on the person indicating that the
individual is diabetic patient. The card should bear the name and address of
the patient, the name, address and telephone number of the private doctor or
the diabetic clinic he is attending, the type and amount of insulin being given
and the times of administration. The patient should also be advised to carry in
his pocket or in her hand bag cubes of sugar, glucose tablets or sweet biscuits
which is to be taken at the first sign of faintness or mental confusion (these
are the first signs of hypoglycaemia and may occur if too little food is taken
after an injection of insulin, or after a violent or unaccustomed exercise). The
patient is also shown how to test the blood sugar using the glucometer.
HYPOGLYCAEMIA: - This is also known as insulin coma. It means that there is
too little sugar in the blood. The onset is sudden. The signs and symptoms
include sweating, pallor or flushing of the face, bounding pulse, mental
confusion, obstinacy and some speech disturbance. Convulsions may occur
especially in children
These symptoms are relieved by taking sugar. If the patient is
unconscious, intravenous glucose is given with very good effect (50% glucose
in 100mls water injection or 10% glucose drip is given).
The blood sugar is less than 60gm/dl blood.
HYPERGLYCAEMIA: - This is also known as diabetic coma. It results from too
much sugar in the blood. The onset is gradual. The signs and symptoms
include loss of appetite, vomiting, abdominal pains, rapid-shallow respirations,
drowsiness and lethargy followed by unconsciousness. Large amounts of urine
are passed. There is a distinct sweet smell of acetone in the breath and skin (it
is like new morn hay).
The patient is treated as for shock and kept warm without overheating
to prevent further loss of body fluids. If unconscious, catheterisation is done
to obtain specimen of urine to be tested for sugar, proteins and ketones, the
catheter is left in situ for continuous drainage. Strict fluid balance chart is
maintained. Blood sugar is tested and recorded. Soluble insulin may be
ordered to be given IM, IV or Sc. For the unconscious patient intravenous
infusion may be ordered. If the stomach is filled or distended, then stomach
washout may be ordered to evacuate the remains of any carbohydrate taken
by the patient. Naso-gastric intubation is done for aspiration and feeding
purpose. On recovery from coma, the dosage of insulin is regulated and a
dosage established. Regular urine testing at 4hrly or 6 hrly or 12 hrly intervals
is maintained.
FOODS RESTRICTED IN DIABETES MELLITUS
Sweets, sugars, jams, marmalade, dried fruits, grapes, bananas, fresh
bread, cakes, sweet puddings, pastry, sweet potatoes, sweet wines, and
cordials, alcohol, rice, foofoo, cassava, yams, coco-yams.
FOODS ALLOWED IN DIABETES MELLITUS
Proteins such as meat, fish, cheese poultry, vegetables such as lettuce,
cabbage, cucumber, tomatoes, onions, fhunde; couscous, tosted bread and
biscuits (the starch has been reduced) are allowed but severely restricted and
monitored.
INSULIN
This is a hormone produced by the beta (β) cells of the islets of
langerhans in the pancreas. Insulin is necessary for: -
1. The transport of glucose from the blood stream into the muscles for
energy
2. The storage of glucose into the adipose tissue from the blood stream in
the form of glycogen
3. For the cells of the body and the liver to use up glucose for energy
4. It prevents the liver from converting amino acids and fatty acids into
glucose (i.e. gluconeogenesis which is the conversion of fatty acids and
amino acids into glucose by the liver)
 5. Insulin stimulates the synthesis (building up of more complex substances
from simple substances) of protein in the muscle, liver and adipose
tissue.
6. Insulin prevents the breaking down of adipose tissues.
TYPES OF INSULIN
SOLUBLE INSULIN: - This is given mainly in emergency. It has a rapid action but
lasts only for about 8 hours. It is not suitable for continued treatment because
it would be necessary to give 2 – 3 injections daily. The solution comes in
strengths of 20, 40 and 80 units per ml and should be clear in appearance.
PROTAMINE ZINC INSULIN: - This is absorbed slowly giving an overall effect
for about 18 hours
INSULIN ZINC SUSPENSION SEMI-LENTE: - It has a rapid action after
administration lasting for about 10 hours
1. INSULIN ZINC SUSPENSION ULTRA LENTE: - It acts slowly and is effective
for up to 24 hours
2. INSULIN ZINC SUSPENSION LENTE: - This is a mixture of semi-lente and
ultra-lente, giving a rapid and slow action together to cover up to 24
hours
There are now newer types of insulin thought to cause less local tissue
damage. They are made from beef and procine. They are manufactured under
such names as Act rapid Insulin, and Neulente.
ADMINISTRATION OF INSULIN
Insulin therapy is more effective when the patient’s weight is controlled.
If the patient is obese, then the weight should be controlled because weight
loss may make the patient more receptive to insulin.
Hence insulin therapy is combined with diet therapy exercise.
The diet should be balanced with 30% of carbohydrates, 20% of fat, 30% of
proteins an important factor because it promotes carbohydrate metabolism
and reduces the need for insulin.
Insulin is given for about 20 minutes before meal and after urine testing.
With some physicians, they prefer the administration just immediately before
the meal. They can be given singly or in combination. The dosage is dependent
on the severity; the body weight the patient’s activities and the level of blood
sugar.
 For measurement of insulin, a special syringe is used, it is 1 ml in capacity
and it is divided into 20 marks per ml. one mark represents 4 units of 80 unit’s
strength insulin. Half inch needles are used.
Insulin is supplied in 20, 40, 80 and 100 units per ml; each with a label of
different colour and the number of units clearly marked (but nurses must not
rely on the colour of the label). The injection is checked by an SRN and gives
SC. The sites should be rotated to prevent thickening and disfiguration of the
skin and they include the outer sides of the upper arm, the thighs and the skin
over abdomen.
For the middle-aged, over weight patients, oral drugs like Rastinon,
Diabenese, Daonil, metformine or similar drugs may be ordered for the control
of diabetes. They are used in conjunction with a strict low carbohydrates diet.
They contain substances which increases the output of insulin from the
pancreas. They do not contain insulin and are of no value in the treatment of
severe diabetes.

BLOOD
It plays a very important part in the maintenance of life. It flows through the
body and, when in the capillaries, it is in intimate relationship with the tissues,
taking O2 and other nutritive substances to the tissues and at the same time
removing CO2 and waste products from them. There is about 6 litres (10 pints)
of blood in the adult body i.e. ½ of the total body weight.
SUMMARY OF THE FUNCTIONS OF THE BLOOD
(1)To convey oxygen to the tissues through the Hb in the red cells
(2)To remove waste products from the tissues and convey them to their
organs of excretion
(a)CO2 is carried to the lungs
(b) Urea is carried from the liver to the kidneys for excretion
(c)H2O is carried to the kidneys
(3)To carry nourishment to all parts of the body i.e. digested food stuff and
vitamins)
(4)To carry hormones of the body (i.e. the internal secretion of the ductless
glands e.g. insulin)
(5)To carry antibodies in the immunoglobulin of the serum
 (6)To aid the defence of the body by the phagocytic action of the white cells
COMPOSITION OF BLOOD: - It is compose of two parts
(1)The liquid part which is called the plasma
(2)The solid part which is made up of R.B.C, W.B.C and platelets
Plasma: - this is a clear yellowish fluid which is made up 92% water and carries
Protein, Mineral Salts, Sugar, Enzymes, Antibodies, and Vitamins
Protein: - 7gm/100mls – serum albumin, serum globulin and fibrinogen
Mineral Salt: - Chlorides, sulphates, phosphates of sodium, potassium and
calcium
Urea: - 20 – 40gm/100mls
Glucose: - 70 – 120mg/100mls
Water: - 92%
In addition prothrombin, vitamins, enzymes and anti-bodies are present.
Plasma: - serum + fibrinogen
Serum: - plasma – fibrinogen.
Red Blood Cells/Red Corpuscles/Erythrocytes: - They are the most numerous
cells in the blood = 5,000,000/cubic millimetres. They contain haemoglobin
(HB) contains iron which combines with oxygen. Preferably, the RBC are
referred to as corpuscles rather than cells because they have no nuclei. They
are flattened biconcave circular discs with a thin membrane.
White Blood Cells or Leucocytes: - These are colourless cells with nuclei and
are a little larger than the RBC but are much less numerous =
4,000-11,000/mm3 with an average of 8,000/mm3. The two main groups of
WBC are the: -
(1)Polymorpho nuclear leucocytes whose duty is to protect the body
against the invasion of bacteria and to remove dead or injured tissues
(2)Lymphocytes which are concerned with the immunity mechanisms of the
body.
The Platelets or Thrombocytes: - They are tiny or minute spherical structures
smaller than the RBC, numbering about 250,000/mm3. They assist in the
clotting process of blood by coagulation thus arresting haemorrhage. They are
produced in the bone marrow by the megakaryocytes.
 In certain diseases their number is decreased (thrombocytopenia), the
patient show a tendency to bleed into the skin. Often bleeding from the
mucous membrane occurs.
Blood Group
Normal blood contains certain factors which are responsible for different
blood groups.
In connection with the transfusion of blood, there are four main groups (A, B,
AB and O) according to the factors in the blood stream. It is essential that the
correct type of blood is transfused in each case to avoid fatality.
The division of persons into these four groups depends on the following facts:
-
Human blood serum may contain substances called agglutinins which have the
power of causing the red cells of persons belonging to another group to run
together in clumps (i.e. agglutinate) if they are mixed with this serum.
These substances are designated in the following way: -
The agglutinins are called (alpha) and B or both or no agglutinins A and B. or
both or no agglutinins.
Whereas human red cells may contain agglutinogen (O)
Therefore it follows that a person in Group AB, does not have O or B
agglutinins in his serum otherwise his own red cells would agglutinate making
life impossible.
A person in Group A, means his red cells contain agglutinogen A in his cells and
his serum agglutinins B
A person in Group B, means his red cells have agglutinogen B and his serum
contains agglutinins.
A person in Group O, means his red cells have no agglutinogens and his serum
contains agglutinins A and B.

Group Red Cells Contain Serum Contain

A Agglutinogen A Agglutinins B

B Agglutinogen B Agglutinins &

 AB Agglutinogen A+B No Agglutinins

O No Agglutinogen Agglutinins &+B

Rhesus Factor
This substance was first discovered in the rhesus monkey. Experiments show
that this anti-body or antigen is present in 85%, Rh-ve = 15%
This factor is particularly important in obstetrics, if two parents are Rh + ve,
their offspring will be Rh + ve. If one of the parents is Rh+ve and the other is
Rh-ve, there is a greater probability that the child will be Rh+ve. But if the
child is Rh+ve and the mother is Rh-ve, then in most cases, the mother
becomes sensitive to the Rh+ve factor in the child’s blood and she develops
anti-Rh bodies. In any future pregnancies, this anti-Rh body may affect the
Rh+ve red-cells of the foetus and this condition is called Erythroblastosis
Foetalis. And results in severe and fatal jaundice (Icterus Gravis Neonatorum).
It is also responsible for some cases of repeated still-births or miscarriages.
If a woman who is Rh-ve is transfuses with a Rh+ve, she may develop
anti-Rh bodies in her blood. Consequently if she has a Rh+ve child from a
Rh+ve father, the child may be affected by Erythroblastosis foetalis. Hence all
Rh-ve women in the child-bearing age should only be transfused with Rh-ve
blood.
NB: Transfusion of Rh+ve blood to a person of Rh-ve can be dangerous,
because the Rh-ve blood will produce anti-Rh bodies to destroy the transfused
cells which will eventually lead to death.
Blood Transfusion
Blood transfusion is a life-saving measure but unless very proper precautions
are taken it has great hazards which may be fatal. The indications for blood
transfusion or plasma are: -
(1) Severe haemorrhage (2) severe burns (3) Shock
(4) Severe anaemia (5) In major surgeries (6) In severe
infections (toxic states or toxaemia)
In cases of blood loss, transfusion is indicated when the blood loss is
estimated to have exceeded 20% of the blood volume (=70ml/kg body weight)
Accurate cross-matching to exclude the presence of anti-bodies in the blood
takes 2 – 4 hours but an emergency cross-match may be performed in 20
minutes.
In cases of great urgency, it is permissible 9through potential wasteful of
valuable blood) to give O, Rh-ve blood without cross-matching
The use of a plasma expander such as dextran, dextraven or haemacel may be
given whilst grouping and cross-matching are being done.
Blood for transfusion is collected in containers Acid-citrate dextrose (ACD
Packs) and the blood should be kept in a refrigerator at a temp of 4 – 6 °C, and
after 21 days from date of collection it should not be used. It must not be
frozen. It must be discarded if there is any sign of haemolysis
Cross-matched units of blood must be clearly labelled with the full name, age
of the patient, the ABO and Rhesus grouping, the name of the ward, the
patient’s case number and the serial number of the unit of blood. All these
information must be carefully checked on collection of the blood from the lab
and again at the deb side before transfusion. Mistakes can lead to tragedy.
Special care must be taken when more than one transfusion is in progress at
the same time. Before commencing a subsequent unit the same strigent
checking procedure is adopted.
Veins of the arm are preferred especially those near the wrist, veins of the
leg should be avoided for transfusion, because deep venous thrombosis is a
risk and the patients movements are restricted.
The standard transfusion fluids are (1) Whole Blood (2) Packed Cells
(3) Plasma.
Whole Blood: - This is given to replace loss of blood due to haemorrhage
which results in the reduction of red cells, haemoglobin and oxygen.
Packed Cells: - This is blood from which some of the plasma has been
removed. This is used where extra HB is needed without increasing the
circulating volume in the body. It is often used in the treatment of severe
anaemia. It is given to patients with diminished cardiac reserve.
Plasma: - This may be separated from the cells and dried. When required for
use distilled water is added. The plasma increases the circulating volume and
contributes protein. It is used in the treatment of septicaemia, shock, burns,
malnutrition or where there is severe loss of body fluids other than blood.
Plasma protein substitute is also available ready for use (e.g. Haemacel,
Dextran, Destraven). Plasma protein may also be give temporarily to treat
haemorrhage until blood is available but their transfusion may only start after
blood for grouping and cross-matching has been taken from the patient.
Requirements for Blood Transfusion
Tray with……..
 Gallipot with dry swabs
 Gallipot with spirit swabs
 Assortment of canula (green colour)
 A pair of sterile gloves
 Receiver for soiled swabs
 Blood giving set or sangofix
 Tourniquet or sphygmomanometer
 Small mackintosh and towel
 Strapping and scissors
 Splint and bandage
 The blood itself and the prescription sheet
In addition drip stand and anglepoise lamp.
Precautions for Blood Transfusion
a. Before the Transfusion
1. Check and record the TPR and B/Pʼ, to establish a baseline figure and to
detect any abnormality. This should be done before the commencement
of the transfusion, any abnormality is reported.
2. Give any pre-medication ordered 30 – 60 minutes before transfusion.
Such pre-med includes anti-malaria (chloroquire inj) + Anti-histamines
(Inj Piriton or Phenergan or Antizan or Tavergyl) + at-time diuretics (Tabs
Lasix)
3. Collect the blood from the lab using the pink blood form and a towel to
wrap it. It should be cross-checked with the lab technician for
a. Name and ward of the patient
b. The group and Rh factor
c. The serial number of the blood
d. The date of collection and expiration
e. The signature of the technician that the blood is compartible
4. On the ward it is cross-checked with the sister or nurse-in-charge more
especially when more than one transfusion is in progress in the ward.
b. During the Transfusion
1. Regular monitor of the rate of flow
2. Special care should be taken during the transfusion of the first 100mls of
blood because it is at this time that any reaction may appear
3. Continue to monitor and record the vital signs ½ hrly for the first 4 hrs
and 4hrly if satisfactory
4. Regular check the site for swelling or pain
5. Closely match for any sign of reaction to the blood.
Ways of Recognising Blood Reaction
1. Oedema of the eyelid may occur
2. Patient may complain of pain in the chest or lumbar region
3. There may be nausea and vomiting
4. Temperature rises, pulse increases, respiration increases and B.P drops
5. Patient complains of headache
6. There may be rigor
7. The patient is restless and confused
8. Rash may appear on the body
N.B: At the first sign of blood reaction the blood is stopped immediately and
the doctor informed
Procedure for Blood Transfusion
1. The blood is collected from the blood bank 20 – 30 minutes before
transfusion with the pink form after cross-checking with the technician
2. In the ward, it is cross-checked with the sister or nurse-in-charge
3. The pre-med is given 30 minutes before the transfusion after explaining
to the patient
4. Allow the patient to empty his bladder and bowel
5. After the time lapse, the tray and drip stand are brought to the bed side
and the bed screened
6. Position the patient comfortably and expose the arm to be used with the
mackintosh and towel underneath it
7. The tourniquet is applied to the arm, the vein selected and the area
swabbed
8. The doctor wears the gloves, chooses the canula and actually goes into
the vein
9. The rate of flow is regulated, the strapping applied, the splint may or
may not be applied
 10. The mackintosh and towel remove underneath the arm
11. The patient’s vital signs are monitored and observations made
regularly for any abnormality
12. Fluid balance chart is maintained
13. Urinary output is monitored.
Rate of Flow
The usual rate of flow is 30 – 40 drops per minute thereby allowing the blood
to flow for 2 – 3 hours depending on the condition of the patient. Rapid
transfusion may be needed to replace a severe and sudden loss of blood and
in such cases; the time frame is 1 – 2 hrs i.e. 40 – 80 drop per minute.
DIFFICULTIES DURING A TRANSFUSION
There are several difficulties whish may alter the rate of flow of the blood
during transfusion
1. The vein may go into spasms. This is over-come by stroking along the
vein above the injection site
2. The tubing become kinked or pressed upon. This is overcome by
straightening the tub or removing the pressure.
3. The needle may become dislodged. The position of the needle is changed
by very gently lifting the mount to depress the needle point. If this is
unsuccessful because the needle has punctured the walls of the vein
then it has to be rest.
4. An air-lock may block the flow of blood from the bottle this should not
occur if proper care is taken to expel all the air from the tub. If however
an air-lock is present, the tub should be disconnected from the needle or
canal and the blood allowed to run freely expel ling the air-lock before
reconnecting it to the needle.
5. Transfusion or infusions of large volume of fluids can give rise to cardiac
or respiratory distress due to over loading if the fluid flows rapid. But it
can occur in slow transfusion if the heart muscle is weak or there is
chronic anaemia
This distress is recognised by rising pulse rate dyspnoea, cough pain in
the chest and oedema
6. If there is reaction due to incompatibility and blood haemolysis there is
great danger of renal failure due to the haemolysed blood cells blocking
the renal tubules with subsequent suppression of urine and them
uraemia
 COMPLICATIONS OF BLOOD TRANSFUSION
(1)Reaction due incompatibility which may occur if grouping and cross-
matching is not scrupulously carried out sign of reaction includes
tachycardia, rigors and transient jaundice, rash, pain in the lion flowed
by oliguria, anuria, shock and abnormal bleeding (haematuria). The
blood should be stopped immediately.
(2)Jaundice is usually requires no treatment except that the patient’s blood
and the transfusion blood are checked for the cause Donors with history
of hepatitis or malaria or syphilis should be exclude.
(3)Transfusion of large volumes or rapid transfusion may result to cardiac
and respiratory failure. When transfusion must be given to patients with
weakened heart or elderly patients them it is wise to give packed cells.
(4)Thrombophlebitis is likely to occur during prolonged transfusion.
Infection may be associated with extension around the vein.
(5)Septicaemia is race because of the self-stressing properties of blood but
may flow infection of the donor’s blood cross-matching or during its
collection.
PARACENTESIS ABDOMINS OR ABDOMINAL TRAPPING
This is done to withdrew fluid from the peritoneal cavity (i.e. ascites) in case of
liver or cardiac disease and in maligent conditions
This procedure can also be used to insert solutions into the peritoneal or
abdominal cavity
Indications from Paracentesis Abdominis
(1)To obtain a specimen of fluid for analysis
(2)To relive pressure when abdominal fluid interferes with respiration or
bladder function or is compressing the abdominal organs and blood
vessels
(3)To insert substance such as radio actives gold colloid or cytotoxic drugs
into the peritoneal cavity.
(4)To achieve regression of serosae deposits responsible for fluid formation
(sero sea is a seriousmembrane which excludes serum)
Causes of ascites
(1)Inflammatory conditions e.g. tuberculous peritonitis
(2)Renal failure or sub-acute nephritis when there is generalised oedema
 (3)Carcinoma of the abdominal organs
(4)National oedema (kwashiorkor)
(5)Cirrhosis of the liver
(6)Congestive cardiac failure (C.C.F)
(7)Obstruction of the lymphatic drainage from the abdomen.
Requirements on a sterile trolley
Top shelf
- Bowl of sterile dressing and swabs
- Receiver with sutures, ascites Kroch and cannula, forceps, scissors,
Needle Holder
- Receive with rubber tubing, gate clip and glass connector
- Gallipot for locations
- Sterile towels
- Scalpels or No 3 B.P handle and No 11 or 15 blades
- Sterile specimen containers
Bottom shelf
- Antiseptic or cleansing lotion
- Receptacle for drainage
- Mackintosh towel
- Local anaesthetic
- Many-tailed bandages
- 2mls or 5mls syringes and Needle
- Sterile gloves
Inhalations
This is a procedure used in the treatment of respiratory disease or conditions.
It is also used to introduce drugs into the body with act on other systems of
the body. It can be moist or dry. They may either be in the form of vapour or
liquid which easily vaporises or a fine spray (aerosol spray)
Reasons for Giving Inhalations
- To relieve spasms of the bronchial tube as in asthmatic conditions
- For treatment of inflammation of the upper respiratory passages e.g.
common cold, laryngitis
- For introducing antiseptics into the lungs in the treatment of bronchitis
and bronchiectasis
- To loosen secretion and to relieve due to coughing
 - It is used to anesthetise patients
- It is used for introducing drugs into the body which act on other systems
of the body (e.g. to relieve pain in angina pectoris, the drug is in an
ampoule, which is broken into gauze swabs and held to the nose to be
inhaled)
Types of Inhalation
(1)Dry Inhalation: - The drug evaporates rapidly and the vapour is inhaled
quickly e.g. ether, chloroform as given in general anaesthetic
(2)Moist Inhalation:- The drug is added to water at a temperature 70 °c and
the vapour inhaled (e.g. tincture of benzoin compound ¯½ teaspoon is
added to 1 pint of water, menthol crystals -2 or 3 crystals to 1 pint of
water.
Nelsonʼs Inhaler: - This is a special earthenware inhaler with two spouts which
must face in opposite direction when in use; one spout is for the inlet of air
and is party of the bowl of the inhaler.
The other spout is made of glass and is fixed into the cork through which the
steam is inhaled into the mouth.
Requirements for Inhalation Using the Nelsons Inhaler
- Nelsons inhaler standing in a bowl to prevent it from falling over
- Blanket or towel or sheet to cover the patient from being burned by the
inhaler
- Gauze swabs to cover the mouth piece and a strip of strapping to fasten
it
- Medicine measure or teaspoon to measure the drug being used
- Drug for inhalation e.g. tincture of benzoin or menthol crystals
- Sputum mug or sputum carton with disinfectants
- Medical wipes
- Bed table
- Jug of hot water = 180 °F
Method for Using Nelsons Inhaler
(1)Explain the procedure of the patient
(2)Screen the bed
(3)Put the patient in the upright position
(4)Bring the requirements on a tray and place them on the bed table or
locker
 (5)Pour a pint of hot water into the inhaler or at the level of the lower
spout
(6)Check the drug against the patients chart
(7)Measure the drug as ordered, usually 4mls of benzoin to 600mls of hot
water or 2-3 menthol crystals to 600mls of hot water.
(8)Replace the cork and cover the mouth piece with the gauze and then
strap it with strapping
(9)Cover the patient to prevent him from being burnt by the inhaler
(10) The patient now starts the inhalation, he puts his lips to the mouth
piece, he breath in through the mouth and breathe out through the nose
(11) At the end of the procedure, the equipment’s are washed and
replaced in their correct places. The mouth piece is sterilised after being
washed
NB: If the patient is seriously ill, very younger age, then the nurse should not
leave the bedside until the procedure is completed. The inlet must not be
blocked and care must be taken not to tip the inhaler on the chest.
Steam Kettle Inhalation
The kettle is used in conjuction with a tent bed in the treatment of bronchitis.
This is usually used for children.
In a small room, a screen round the head of the bed with a sheet over the top
may replace a full tent.
An electric kettle is used to minimise the risk of fire. The kettle should stand on
a stool and the spout introduced either at the side or the back of the tent. If a
drug is being used, it is added to the boiling water (e.g. tincture of benzoin or
menthol crystals). The temperature inside the tent should be 70 °F.
If the patient is a child, then he needs some form of restraint to keep
him away from the kettle of the steam.
Chest Aspiration or Thoracentesis
This is performed at the bedside to remove fluid from the pleural cavity
surrounding the lungs. Normally, this space contains a minimal amount of fluid
that lubricate the pleural lining around the lungs.
For laboratory analysis, a small amount of fluid can be removed from
the pleural cavity.
 Large amounts of fluid collecting in the pleural cavity due to infiltration
or infection; may have to be removed thereby restoring the space for proper
lung expansion hence improving respiratory function.
Procedure: - The procedure is explained to the patient and a consent form
signed. The patient is positioned upright and asked to bend forward. Leaning
on a bed table over the bed. The area cleaned, draped and local anaesthetic
given. The pillow behind him is removed. The aspiration needle is now
inserted by the doctor and the fluid withdrawn through a syringe or connected
to a catheter and allowed to flow into a sterile closed container. During the
procedure, the patient is observed for alteration in pulse and respiration rate,
and the colour of the skin. After the fluid is aspirated, the catheter or needle is
removed and sterile dressing applied firmly to the site of puncture. The
patient is nursed in the upright position. Observation for any changes in the
pulse and respiration and the general condition of the patient continues, any
abnormality should be reported immediately. Also the patient is observed for
severe coughing or blood sputum. After thoracentesis, the respiration or
breathing is supposed to be easier.
If laboratory analysis is required, the specimen is properly labelled and
sent to the laboratory with the laboratory form.
Requirements on a Sterile Trolley
Top Shelf
- Bowl of sterile swabs and dressing
- Gallipot for cleaning lotion
- Sterile towels
- Sterile container for specimen
- Receiver with 2 dissecting forceps
- Receiver with two-way tap, tubing to fit the tap, 20mls syringe to fit the
tap
Bottom Shelf
- Bottle of cleansing lotion
- Strapping and scissors
- Local anaesthetic
- 2mls or 5mls Syringe and hypodermic needle
- Gloves (size 7 or 8)
- Laboratory request form
Causes of Pleural Effusion
- Tuberculosis
- Malignancy of the lungs
- Congestive Cardiac Failure
- Pneumonia and other infection of the lungs
NB: The insertion of the needle is dependent on the level of the fluid as
indicated by the X-ray films.
Oxygen Therapy
This another form of inhalation
Oxygen is a colourless, odourless gas that forms ⅕ or 20% of the atmospheric
air which we breathe.
Oxygen Therapy can be defined as the provision of an atmosphere of
increased oxygenation and humidity by the use of specialised equipment’s.
They are seriously ill, some find a mask or tent oppressive thereby
experiencing claustrophobia. Hence it the nurse’s duty to explain the
procedure to the patient and calming down the patient
Oxygen is stored in several ways but the most common are the piped-in
system and the cylinder system.
In the piped-in system, the oxygen is stored in a large holding tank that is
located separate from the facility. The oxygen comes to the facility through
pipes with outlets on the wall by the bedside; a special flow meter is attached
to the outlet at the wall.
In the cylinders that are black with white tops fitted with a spanner by which
the gas can be turned on, and a fine adjustment valve by which the flow is
controlled.
The Oxygen Apparatus Consists of the Following Parts: -
Flow Meter: - This is a device attached to the oxygen outlet (cylinder or piped-
in system) to regulate the amount and pressure of oxygen delivered. It is
marked in litres and it indicates the rate that should be given to the patient
according to the physcians prescription, usually it is from 4 – 6 litres per
minute. The flow meter may be of the dial gauge or the bobbin (mercury ball)
type.
In the latter type, a bobbin inside agraduated glass tube rises as oxygen passes
through and the height of the bobbin against the scale shows the amount of
oxygen passing through.
Pressure gauge: - This is an additional gauge attached directly to the cylinder
to regulate the pressure and register the amount of oxygen in the cylinder; it
shows whether the cylinder is empty or full. The needle points to the red area
warning the staff that the cylinder must be replaced.
The Regulator or Controlling Valve: - At one end is the flow-meter and at the
other end is a long rubber tubing which is attached to the face mask. It has a
tap which is used to turn the oxygen on and off using a spanner.
Precautions Taken When Oxygen is in Progress
Oxygen itself is not explosive but it supports combustion i.e. extremely rapid
burning takes place in the presence of high oxygen concentration so that it
appears that the oxygen itself were explosive. Thus it is essential to prevent
sparks or fire in an environment where oxygen is being used.
(1)No spark or flame or electrical equipment should be near the oxygen
cylinder
(2)The oxygen cylinder is opened outside the ward
(3)Dust and grit should be removed before fixing the attachment by
allowing some oxygen to flow out thus blowing out the dust and grit
(4)The patient and visitors are told about the precaution when oxygen is in
progress
(5)A “No Smoking” sign in red should be put in visible spots
(6)Empty cylinders are removed from the bedside immediately marked
empty; the fitment removed and keep separately
(7)The correct amount of oxygen should be given to prevent complications
(8)Ensure that the masks and tubing are in correct order and position that
the patient gets the correct oxygen
(9)Avoid using greasy or oily products
(10) Keep the oxygen cylinder always in the upright position
(11) Fire extinguisher should be readily available
Complications of Oxygen Therapy
(1)Fire and explosions
(2)Carbondioxide narcosis (narcosis is a state of unconsciousness produced
by a narcotic drug, it is a state of unnatural sleep)
 (3)Brain damage and blindness from excessive oxygen
(4)Dryness of the mouth and nose
(5)Confusion
(6)Air swallowing
Indications for Oxygen Therapy
It is given when the patient is unable to obtain sufficient oxygen from the air
by natural means as a result: -
(1)Acute lower respiratory track conditions
(2)Acute pulmonary oedema
(3)In asthmatic conditions
(4)Carbondioxide poisoning or poisoning by other gases
(5)Hypoxia (reduced oxygen supply e.g. high altitudes or under water
conditions)
(6)Chronic obstructive pulmonary diseases
(7)Intra and post-operative patients
The Therapy Has Three Fundamental Goals
(1)Improved tissue oxygenation
(2)Decreased respiration in dyspnoeic patients
(3)Decreased work of the heart in cardiac disease patients
Humidification
The nasal mucosa is designed to moisten the air hat passes through the nose
to the lungs. Anytime that oxygen is administered through a tracheostomy or
endotracheal tube so that the normal moistening mechanism is by-pass
humidification of the inspired air and oxygen is essential.
Humidification is provided by humidifiers which are containers of sterile water
which are attached to the administration device, the oxygen flows through
them and picks up moisture thereby reducing the chances of dryness of the
mouth, nose and respiratory track.
The water must be sterile to prevent injection and must be changed every 24
hours.
Ways by Which Oxygen can be Administered
(1)By nasal catheter
(2)By Tudor Edwards spectacle or Nasal Canula
(3)By BLB mask (Booth by, lovelace and Bulbulian)
 (4)By disposable polythene mask
(5)The oxygen tent
Requirement for Oxygen Therapy by Nasal Catheter
(1)Oxygen cylinder with flow meter and length of rubber tubing attached
(2)A humidifier with warm sterile water
(3)Small glass connector for connecting the rubber tubing to the nasal
catheter
(4)Two nasal catheters
(5)Gallipot with cleansing lotion
(6)Gallipot with gauze or cotton wool swabs
(7)Gallipot with liquid paraffin or Vaseline to lubricate the nasal catheter
(8)Receiver with soiled swabs
Method for Oxygen Therapy Using the Nasal Catheter
(1)It conscious, explain the procedure to the paint
(2)Screen the bed
(3)Bring the oxygen cylinder and other requirements to the bedside.
(4)Put the patient’s in the fowler’s position
(5)Wash your hands and dry them
(6)Clean the nostril with swabs and lotion
(7)Lubricate the catheter very lightly and gently insert it into the nostrils for
about 3’’ along the flour of the nostril and strap into position on the
cheek.
(8)Check the prescription sheet and then turn on the oxygen as ordered,
usually about 4-6 litres per minute
(9)Secure the rubber tubing to the patient s mattereess with safety pin
(10) Enforce ‘’No smoking’’ sign
(11) If the anxious or restless, stay at the bedside to calm the patient
(12) Monitor the patient for breathing, skin colour, mental status and
comfort.
(13) Reccord the administration.
NB: The nasal catheter is not frequently used because it cause it causes
irritation, to decrease irritation to the nasal mucosa, the catheter is charged
to the other nostril every 8 hours
The catheter is used if a tent is not availed or a face mask in not
suitable e.g. where there is facial injuries. It is less efficient then the mask or
tent, it wastes the oxygen and the patient cannot tolerate a flow greater than
 4 litres per minute. When using the nasal catheter, the oxygen has to be
humidified with a humidifier because dry oxygen irritates the nasal passages.
The Nasal Cnnula or Nasal Prongs or Tudor Eduwards Spectacle
These are spectacle frames fitted with hallow mental tubes on
which a fine rubber tubing is attached for insertion into the nostrils.
The method of application is the same as for the nasal cattieters. It
is worn on the patient in the same way as an ordinary pair of spectacle.
The B.L.B Masks
This apparatus consists of a rubber face mask made to cover the
nose and the mouth joined by a metal connecting device to a thin rubber bag
similar to a football bladder. The mask is fastened around the head by a
rubber strap. With a flow rate of 7 litres per minute, an alveolar
concentration of 90% of oxygen can the obtained.
The rubber bag has a capacity of about 700 mls and should be slightly
distended when in use when the patient breaths out, the expired air enters
the bag and is mixed with the incoming oxygen. When the patient breaths in
again, the mixture of air and oxygen passes into the mask and into the
nostrils.
The disposable polythene mask
The type of mask is lighter in weight and as it is inexpensive, it can
be destroyed after use and therefore presents no problem of sterilisation. It
consists of two pockets, one inside the other and fastens together at the top.
The oxygen enters through outer pocket to the patient. An elastic band is
used to keep it round the head closely and comfortably. So when the oxygen
supply accidently runs out, the cuff will deflate thus calling attention to the
failure, meanwhile the patient will continue to breath atmospheric air.
The Venturi Mask
This is designed to give accurate control of oxygen concentration so
that it does not rise high enough to cause respiratory depression, but is
sufficient to relive anoxia. The range of controlled to concentration is 24-35%.
The face piece is edge with foam rubber so that it fits closely and comfortable
round the patient’s face.
The Oxygen Tent
This is a transparent air tight compartment into which face oxygen flows over
ice to prevent the temperature inside the tent rising above 18°C or 65°F.
Oxygen tents are made in various sizes to fit beds or cots, and have an
aperture in front through which the patient receives attention without
interrupting the flow of oxygen
Again the oxygen tents are now seldom used except for paediatric patients
because some patients experience claustrophobia, the tent also requires much
more oxygen to maintain the desired concentration, therefore they are
hazardous, and costly.

LAST OFFICES
This is the last service that the nurse is able to carry out for the patient
and must be performed with the utmost reverence. It is done by two nurses
working quietly with no unnecessary talking between them.
When it is seen that death is approaching, the Minister of Religion may
be sent for. The relatives are notified by the Ward-Sister or deputy. Relatives
should be treated with sympathy courtesy and quiet consideration.
They may be allowed to stay at the bedside if they wish. If they are shocked,
they should be treated before allowed to leave the hospital. Before leaving,
they are advised by the Ward-Sister on the issue of the death Certificate, the
transportation of the corpse to the mortuary, possible post-mortem and the
collection of the patient’s belongings. Nurse must not express their opinions
as to the cause of death; all enquires are referred to the Sister who will in turn
refer them to the doctor in charge of the case.
Last offices are carried out in two stages.
THE FIRST STAGE: - This is carried out as soon as possible after death has
occurred before rigor mortis (stiffening of the muscles) set in.
Place the bed sheet and a pillow under the head. All equipment’s (such
as air-ring, bed-cradle, oxygen apparatus, IV fluids, Naso-gastric tubes,
drainage tubes, catheters) are removed from the patient and the bedside.
Jewellery should be removed with the exception of wedding-rings. The
patient’s eyes are closed and the lids covered with damp cotton-wool swabs. A
small pillow is placed under the chin to keep the lower jaw closed or
alternatively the chin is bandaged to the head. The body is straightened with
the arms at the side or over the genital area. A pad of cotton wool is placed
between the ankles before tying them together. The body is covered with a
sheet and left for one hour. During this time the equipment’s for the second
stage are collected and assembled on a trolley.
 The exact time of death is noted and recorded.
THE SECOND STAGE: - At this stage, the nurse do not leave the bedside until
the procedure is completed. The body is washed thoroughly with soap and
water. The nails are cut short and left very clean. If there is any beard, it may
or may not be removed. If there is a wound, the dressings are changed. The
hair is combed or brushed and arranged neatly and attractively; the hair of a
female patient may be tied with a white ribbon.
A mortuary sheet is rolled underneath the patient and the bottom sheet
removed.
A label is attached to the wrist or the ankle or the chest. The rectum and
nostrils are plugged with cotton wool (and the vagina for females). The patient
is then wrapped with the mortuary sheet and another label attached on top.
The body should be taken from the ward as quickly and as quietly as possible.
The possessions of the patient are made in a parcel. All valuables and
documents are listed, in the property book, cross-checked and handed over to
the Ward-Sister.
All equipment’s used by the patient either disposed of or washed and
disinfected. Sheets and blankets are sent to the laundry. Pillows and
mattresses are placed in the sun. The bedstead is washed and carbonized. The
bed-locker and bed table are washed inside out and then carbonized.
The bed is then remade with fresh linen awaiting a new patient. During
the whole procedure, the screen should remain in place until the bed has been
remade and the locker repositioned.
The trolley is taken to the sluice, cleaned and disinfected. The bowls and
instruments are washed and sterilised.
The identification label should state the patients name, age, ward,
religion, and diagnosis, the doctor in charge of the case, date and exact time of
death.
The individual is only called a corpse after he/she has been certified
dead by the doctor.

REQUIREMENTS FOR LAST OFFICES ON A TROLLEY

 Receiver with scissors and tape or rope
 Receiver with comb and hair brush
 2 identification labels
 Bowl of warm water
 Receiver with brown and white cotton wool
 Mortuary sheet
 Soap in a soap dish
 Receiver with two flannels
 Receiver with dressing forceps and dressings
 Bath towel
 Receiver for soiled instruments
 Receiver for soiled dressings