NTRODUCTION

Nursing
Definition:
It is assisting the individual, sick or well in the performance of those
activities contributing to health or its recovery (to peaceful death) that he
will perform unaided, if he had the necessary strength, will or knowledge
and to do this in such a way as to help him gain independence as rapidly
as possible (Virginia Henderson 1960).
CARE OF THE PATIENT UNIT AND
EQUIPMENT
General Instructions for All Nursing Procedures
1. Wash your hands before and after any procedure.
2. Explain procedure to patient before you start.
3. Close doors and windows before you start some procedures like
bed bath and back care.
4. Do not expose the patient unnecessarily.
5. When ever possible give privacy to all patients according to the
procedure.
6. Assemble necessary equipment before starting the procedure.
7. After completion of a procedure, observe the patient reaction to the
procedure, take care of all used equipment and return to their
proper place.
8. Record the procedure at the end.
A. Care of Patient Unit
I. THE PATIENT UNIT
A. Patient Care Unit: is the space where the patient is
accommodated in hospital and consists of the bed, an over bed
table, a bedside table, and possibly a chair. There may also be
closet space or drawer.
The patient unit is of three types:
1. Private room – is a room in which only one patient be
admitted
• 2. Semi private room – is a patient unit which can
• accommodate two patients
• 3. Ward- is a room, which can receive three or more patients.
• Consists of a hospital bed, bed side stand, over bed table,
• chair, overhead light, suction and oxygen, electrical outlets,
• sphygmomanometer, a nurses call light, waste container and
• bed side table.
B. Hospital Bed
• Gatch bed: a manual bed which requires the use of hand
racks or foot pedals to manipulate the bed into desired
positions i.e. to elevate the head or the foot of the bed
⇒ Most commonly found in Kenya hospitals
⇒ Are less expensive and free of safety hazard
⇒ Handles should be positioned under the bed when not in
use
• C. Side rails
• • Half rails – run only half the length of the bed, are meant to
• prevent client falls
• • It should be attached to both sides of the bed
• ♦ Rails
• – Full rails – run the length of the bed
• – Half rails _ run only half the length of the bed and
• commonly attached to the pediatrics bed.
• D. Bed Side Stand
• • Is a small cabinet that generally consists of a drawer and a
• cupboard area with shelves
• • Used to store the utensils needed for clients care. Includes
• the washbasin (bath basin, emesis (kidney) basin, bed pan
• and urinal
• • Has a towel rack on either sides or along the back
• • Is best for storing personal items that are desired near by or
• that will be used frequently
• E.g. soap, shampoo, lotion etc
• E. Over Bed Table
• • The height is adjustable
• • Can be positioned and consists of a rectangular, flat surface
• supported by a side bar attached to a wide base on wheels
• • Along side or over the bed or over a chair
• • Used for holding the tray during meals, or care items when
• completing personal hygiene
• F. The Chair
• • Most basic care units have at least one chair located near
• the bedside
• For the use of the client, a visitor, or a care provider
G. Overhead Light (examination light)
• Is usually placed at the head of the bed, attached to either
the wall or the ceiling
• A movable lamp may also be used
• Useful for the client for reading or doing close work
• Important for the nurse during assessment
H. Suction and Oxygen Outlets
• Suction is a vacuum created in a tube that is used to pull
(evacuate) fluids from the body E.g. to clear respiratory
mucus or fluids
• Oxygen is one of the gases frequently used for health care
today. Oxygen is derived through a tube.
 I. Electrical Outlets
• Almost always available in the was at the head of the bed
J. Sphygmomanometer
• The blood pressure assessment tool, has two types:
1. An aneroid
2. Mercury, which is frequently used during nursing
assessment.
• K. Call Light
• • Used for client’s to maintain constant contact with care
• providers
• II. Care of Patient Unit
• • Nursing staffs are not responsible for actual cleaning of dust
• and other dirty materials from hospital. However, it is the staff nurses'
duty to supervise the cleaner who perform this job.
• A. General Rules for Cleaning
• • Dry dusting of the room is not advisable.
• • Dusting should be done by sweeping only
• • Use a damp duster for collecting dust
• • Dust with clear duster
• • Collect dust at one place to avoid flying from place to place
• • Dusting should be done without disturbing or removing the patients
• from bed
• • Dusting should be done from top to bottom i.e. from upward to
• downward direction
• • While dusting, take care not to spoil the beds or walls or other
• fixtures in the room or hospital ward
• • While dusting, wounds or dressing should not be opened by other
• staff
• • There should be a different time for dusting daily
Admission and Discharge

A. Admission
Admission is a process of receiving a new patient to an individual unit
(ward) of the hospital. (Hospitalized individuals have many needs and
concerns that must be identified then prioritized and for which action
mustbe taken).
Purpose
• To help a new patient to adjust to hospital
• To alleviate the patient's fear and worry about the hospitalization.
Nurse's Responsibilities During Admission of a Patient to Hospital
1. Check for orders of admission
2. Assess the patient's immediate need and take action to meet them.
These needs can be physical (e.g. acute pain) or emotional
distress, (upset)
3. Make introduction and orient the patient
• Greet the patient
• Introduce self to the patient and the family
• • Explain what will occur during the admission process
• (admission routines) such as admission bath, put on hospital
• gowns etc.
• • Orient patient to individual unit: Bed, bathroom, call light,
• supplies and belonging; and how these items work for
• patient use.
• • Orient patient to the entire unit: location of nurses office,
• lounge etc.
• • Explain anything you expect a patient to do in detail. (this
• helps the patients participate in their care).
• • Introduce other staff and roommates
4. Perform base line assessment
a. Observation and physical examination such as:
• Vital signs; temperature pulse, respiration and blood
pressure
• Intake and output
• Height and weight (if required)
• General assessment
b. Interview patient and take nursing history to determine what
medication the patient is currently taking, any allergies, and
patient's entering complaints and concern.
5. Take care of the patient's personal property
• Items that are not needed can be sent home with family
members
• Other important items can be kept at bedside or should be
put in safe place by cabling with patient's name.
6. Record keeping or maintaining records
• Record all parts of the admission process
• Other recording include
⇐ Notification to dietary departments
⇐ Starting kardex card and medication records
⇐ If there is specific form to the facility, complete it.
B. Discharging a Patient
Indications for discharge
• Progress in the patient's condition
• No change in the patient's condition (Referral)
• Against medical advice
• Death
Nurse's Responsibility During Discharging a Patient
1. Check for orders that a patient need to be discharged
2. Plan for continuing care of the patient
• Referral as necessary
• Give information for a new person involved in the patient
care.
• Contact family or significant others, if needed.
• Arranging transportation
3. Teaching the patient about
• What to expect
• Medications (Treatments)
• Activity
• Diet
• Need for continued health supervision
Discharge summaries usually include:
• Description of client’s condition at discharge
• Current medication
• Treatment (e.g. Wound, care, O2 therapy)
• Diet
• Activity level
• Restrictions
Reason for referral include the following:
• Any active health problems
Current medication
• Current treatments that are to be continued
• Eating and sleeping habits
• Self-care abilities
• Support networks
• Life-style patterns
• Religious preferences
Discharging a patient against medical advice (AMA)
1. When the patient want to leave an agency without the permission
of the physician - unauthorized discharge the following activities
are indicated:
2. Ascertain why the person wants to leave the agency
3. Notify the physician of the client’s decision
4. Offer the patient the appropriate form to complete
5. If the client refuses to sign the form, document the fact on the form
and have another health professional witness this
6. Provide the patient with the original of the signed form and place a
copy in the record
7. When the patient leaves the agency, notify the physician, nurse in
charge, and agency administration as appropriate
• Assist the patient to leave as if this were a usual discharge
from the agency (the agency is still responsible while the
patient is on premises)
Definition of Signs and Symptoms

Objective information (sign):

The health personnel and the patient readily observe those signs such
as;
swelling, redness rash, body discharge, vital signs, laboratory results
Subjective information (symptom)
• Felt by the patient only
• Experienced by the patient them selves and made known to the
health personnel only through complaints of patient. E.g. Nausea,
headache, numbness
Safety and Comfort Measures and
Devices
1. Cotton Rings: are small circles of cotton rolled with gauze or
bandage with hole in the middle.
Used to relieve pressure from small areas such as the elbows and
hells
2. Air Rings:
• Should be filled with air and covered with pillow case
• Not commonly used
• Should be changed frequently
• Used to relieve pressure from the buttocks (to prevent bed
sore)
3. Cradles (Bed Cradle):
• Also called Anderson frame.
• Is a frame, which is made of wire, wood or iron.
• Designed to keep the top bedclothes off the feet, legs, and
even abdomen of client in case of injury.
4. Pillow:
• Placed under head, back, between knees or at the foot of
the bed to prevent foot drop and keep the patient.
• Are used to give comfort, support and to position a patient
properly.
5. Sand Bags:
• Are heavy, cylindrical or rectangular sand-filled bags.
• Are used for supporting or immobilizing a limb.
• They should be covered with towel and placed one on either
side of a limb (or part to be immobilized).
6. Splints:
Are rigid supports that help maintain the wrists in hyperextension as
a means of
Preventing palmar flexion and constructors.
7. Fracture boards:
• Used to make the bed firm and to prevent bed from sagging.
• They are placed under the mattress of patients with fracture
8. Backrest:
Used for elevating and supporting the head and back of the
patient.
• Gatch beds have back rest which can be elevated or lowered
as desired
• Pillows or boards can be used if gatch bed is not available
.
9. Foot rest (board):
• Are rigid, vertical structures.
• Are placed at the foot of the bed.
• Help to maintain the ankles in their normal functional position
in order to prevent foot drop and also prevent the patient
from sliding down.
• Should be padded for support.
• Should be adjusted to the client's height so that the soles rest
firmly against it and the ankles are maintained at 900
Lifting and Moving a Patient

Body Mechanics: is the effort; coordinated, and safe use of the body to
produce motion and maintain balance during activity
• A person maintains balance as long as the line of gravity
passes through the center of the body and the base support
Line of gravity: an imaginary vertical line drawn through an object’s
center of gravity
• The point at which all of the mass of an object is centered
• Base of support: the foundation on which an object rests
Principles
• Balance is maintained and muscle strain is avoided as long as the
line of gravity passes through the base of support
• The wider the base of support and the lower the center of gravity,
the greater the stability
• Objects that are close to the center of gravity are moved with the
least effort
Purpose of Proper Body Mechanics
• Promotes body musculoskeletal functioning
• Reduces the energy required to move and maintain balance
• Reduce fatigue and decreases the risk of injury
• Facilitates safe and efficient use of appropriate groups of muscles
The center of gravity of a well-aligned standing adult is located slightly
anterior to the upper part of the sacrum.
Standing position posture: is unstable because of a narrow base of
support, a high center of gravity and a constantly shifting line of gravity.
Moving a Patient
Purpose:
o To increase muscle strength and social mobility
o To prevent some potential problems of immobility
o To stimulate circulation
o To increase the patient sense of independence and self-esteem
o To assist a patient who is unable and move by himself
o To prevent fatigue and injury
o To maintain good body alignment
BED MAKING
In most instances beds are made after the client receives certain care
and when beds are unoccupied. Unoccupied bed can be both open and
closed.
Closed bed: is a smooth, comfortable and clean bed, which is prepared
for a new patient
• In closed bed: the top sheet, blanket and bed spread are drawn up
to the top of the bed and under the pillows.
Open bed: is one which is made for an ambulatory patient are made in
the same way but the top covers of an open bed are folded back to make
it easier of a client to get in.
Occupied bed: is a bed prepared for a weak patient who is unable to
get out of bed.
Purpose:
1. To provide comfort and to facilitate movement of the patient
2. To conserve patient’s energy and maintain current health status
Anesthetic bed: is a bed prepared for a patient recovering from
anesthesia
⇒ Purpose: to facilitate easy transfer of the patient from stretcher
to bed
Amputation bed: a regular bed with a bed cradle and sand bags
⇒ Purpose: to leave the amputated part easy for observation
Fracture bed: a bed board under normal bed and cradle
⇒ Purpose: to provide a flat, unyielding surface to support a
fracture part
Cardiac bed: is one prepared for a patient with heart problem
⇒ Purpose: to ease difficulty in breathing
Order of Bed Covers
1. Mattress cover
2. Bottom sheet
3. Rubber sheet
4. Cotton (cloth) draw sheet
5. Top sheet
6. Blanket
7. Pillow case
8. Bed spread
Note
• Pillow should not be used for babies
• The mattress should be turned as often as necessary to prevent
sagging, which will cause discomfort to the patient.
A. Closed Bed
• It is a smooth, comfortable, and clean bed that is prepared for a new
patient
Essential Equipment:
• Two large sheets
• Rubber draw sheet
• Draw sheet
• Blankets
• Pillow cases
• Bed spread
Procedure:
• Wash hands and collect necessary materials
• Place the materials to be used on the chair. Turn mattress and
arrange evenly on the bed
• Place bottom sheet with correct side up, center of sheet on center
of bed and then at the head of the bed
• Tuck sheet under mattress at the head of bed and miter the corner
• Remain on one side of bed until you have completed making the
bed on that side
• Tuck sheet on the sides and foot of bed, mitering the corners
• Tuck sheets smoothly under the mattress, there should be no
wrinkles
• Place rubber draw at the center of the bed and tuck smoothly and
tightly
• Place cotton draw sheet on top of rubber draw sheet and tuck.
The rubber draw sheet should be covered completely
• Place top sheet with wrong side up, center fold of sheet on center
of bed and wide hem at head of bed
• Tuck sheet of foot of bed, mitering the corner
• Place blankets with center of blanket on center of bed, tuck at the
foot of beds and miter the corner
• Fold top sheet over blanket
• Place bed spread with right side up and tuck it
• Miter the corners at the foot of the bed
• Go to other side of bed and tuck in bottom sheet, draw sheet,
mitering corners and smoothening out all wrinkles, put pillow case
on pillow and place on bed
• See that bed is neat and smooth
• Leave bed in place and furniture in order
• Wash hands
B. Occupied Bed
Purpose: to provide comfort, cleanliness and facilitate position of the
patients
Essential equipment:
• Two large sheets
• Draw sheet
• Pillow case
• Pajamas or gown, if necessary
Procedure:
• If a full bath is not given at this time, the patient’s back should be
washed and cared for
• Wash hands and collect equipment
• Explain procedure to the patient
• Carry all equipment to the bed and arrange in the order it is to be
used
• Make sure the windows and doors are closed
• Make the bed flat, if possible
• Loosen all bedding from the mattress, beginning at head of the
bed, and place dirty pillow cases on the chair for receiving dirty
linen
• Have patient flex knees, or help patient do so. With one hand over
the patient’s shoulder and the shoulder hand over the patient’s
knees, turn the patient towards you
• Never turn a helpless patient away from you, as this may cause
him/her to fall out bed
• When you have made the patient comfortable and secure as near
to the edge of the bed as possible, to go the other side carrying
your equipment with you
• Loosen the bedding on that side
• Fold, the bed spread half way down from the head
• Fold the bedding neatly up over patient
Roll dirty bottom sheet close to patient
• Put on clean bottom sheet on used top sheet center, fold at center
of bed, rolling the top half close to the patient, tucking top and
bottom ends tightly and mitering the corner
• Put on rubber sheet and draw sheet if needed
• Turn patient towards you on to the clean sheets and make
comfortable on the edge of bed
• Go to the opposite side of bed. Taking basin and wash cloths with
you, give patient back care
Remove dirty sheet gently and place in dirty pillow case, but not on
the floor
• Remove dirty bottom sheet and unroll clean linen
• Tuck in tightly at ends and miter corners
• Turn patient and make position comfortable
• Back rub should be given before the patient is turned on his /her
back
• Place clean sheet over top sheet and ask the patient to hold it if
she/he is conscious
• Go to foot of bed and pull the dirty top sheet out
• Replace the blanket and bed spread
• Miter the corners
• Tuck in along sides for low beds
• Leave sides hanging on high beds
• Turn the top of the bed spread under the blanket
• Turn top sheet back over the blanket and bed spread
• Change pillowcase, lift patient’s head to replace pillow. Loosen top
bedding over patient’s toes and chest
• Be sure the patient is comfortable
• Clean bedside table
• Remove dirty linen, leaving room in order
• Wash hands
GENERAL CARE OF THE PATIENT
A. Bed Bath
Equipment
• Trolley
• Bed protecting materials such as rubber sheet and towels
• Bath blanket (or use top linen)
• Two bath towels
• Clean pajamas or gown
• Additional bed linens
• Hamper for soiled cloths
• Basin with warm water (43-460
c for adult and 38-400
c for children)
• Soap on a soap dish
• Hygienic supplies, such as, lotion, powder or deodorants (if
required)
• Screen
• Disposable gloves
Procedures
1. Prepare the patient unit
• Close windows and doors, use screen to provide privacy.
2. Prepare the patient and the bed
• Place the bed in high position to reduce undue strain on the
nurse's back
• Remove pt's gown and pajamas
• Assist pt to move toward you so it facilitates access to reach
pt without undue straining. Position the pt in supine, semi -
Fowler’s or Fowler’s depending on the pt's condition.
3. Make a bath mitt with the washcloth, so it retains water and heat
than a cloth loosely held
4. Washing body parts
• Expose only the parts of the patient's body being washed
avoid unnecessary exposing.
• Wash, rinse and dry each body parts thoroughly using
washing towels and paying particular attention to skin folds.
• Suggested order for washing body parts;
Face, ear, neck
⇒ Arms and hands further away from the nurse
⇒ Chest
⇒ Arms and hands nearest to the nurse
⇒ Buttocks and genital area
⇒ Change the water after it gets dirty
⇒ If possible assist patient to wash own face, hands,
feet and genital area by placing the basin on
bed.
Assist the patient with grooming
• Apply powder lotion or deodorants (of pt uses)
• Help patient to care for hair, mouth and nails.
5. Recomfort the patient
• Change linen if soiled
• Arrange the bed
• Put pt in comfortable position
• Remove the screen
6. Give proper care of materials used for bathing
• Document and report pertinent data
• Observation of the skin condition
• General appearance or reaction of the pt
• Type of bath give
Report any abnormal findings to the nurse in charge
Mouth Care
Purpose
• To remove food particles from around and between the teeth
• To remove dental plaque to prevent dental caries
• To increase appetite
• To enhance the client’s feelings of well-being
• To prevent sores and infections of the oral tissue
• To prevent bad odor or halitosis
• Should be done in the morning, at night and after each meal
• Wait at least for 10 minutes after patient has eaten
Equipments
• Toothbrush (use the person’s private item. If patient has none use
of cotton tipped applicator and plain water)
• Tooth paste (use the person’s private item. If patient has none of
use cotton tipped applicator and plain water)
• Cup of water
• Emesis basin
• Towel
• Denture bowel (if required)
Procedure
1. Prepare the pt:
• Explain the procedure
• Assist the patient to a sitting position in bed (if the health
condition permits). If not assist the patient to side lying with
the head on pillows.
• Place the towel under the pt's chin.
• If pt confined in bed, place the basin under the pt's chin
2. Brush the teeth
• Moisten the tooth with water and spread small amount of
tooth paste on it
• Brush the teeth following the appropriate technique.
Brushing technique
• Hold the brush against the teeth with the bristles at up
degree angle.
• Use a small vibrating circular motion with the bristle at the
junction of the teeth and gums use the some action on the
front and the back of the teeth.
• Use back and forth motion over the biting surface of the
teeth.
3. Give pt water to rinse the mouth and let him/her to spit the water
into the basin.
• Assist patient in wiping the mouth
4. Recomfort the pt
• Remove the basin
• Remove the towel
• Assist the patient in wiping the mouth
• Reposition the patient and adjust the bed to leave patient
comfortably
5. Give proper care to the equipments
6. Document assessment of teeth, tongue, gums and oral mucosa.
Report any abnormal findings.
Mouth care for unconscious patient
™ Position
• Side lying with the head of the bed lowered, the saliva
automatically runs out by gravity rather than being aspirated
by the lungs or if patient's head can not be lowered, turn it to
one side: the fluid will readily run out of the mouth, where it
can be suctioned
• Rinse the patient's mouth by drawing about 10 ml of water or
mouth wash in to the syringe and injecting it gently in to
each side of the mouth
• If injected with force, some of it may flow down the clients
throat and be aspirated into the lung
• All the rinse solution should return; if not suction the fluid to
prevent aspiration
Perineal Care (Perineal – Genital Care)
Perineal Area:
• Is located between the thighs and extends from the top of the
pelvic bone (anterior) to the anus (posterior)
• Contains sensitive anatomic structures related to sexuality,
elimination and reproduction
Perineal Care (Hygiene)
• Is cleaning of the external genitalia and surrounding area
• Always done in conjunction with general bathing
Patients in special needs of perineal care
• Post partum and surgical patients (surgery of the perineal area)
• Non surgical patients who unable to care for themselves
• Patients with catheter (particularly indwelling catheter)
Other indications for perineal care are:
1. Genito- urinary inflammation
2. Incontinence of urine and feces
3. Excessive secretions or concentrated urine, causing skin irritation
or excoriation
4. Presence of indwelling urinary (Foley) catheter
5. Post partum care
6. Care before and after some types of perineal surgery