BASIC NURSING

LECTURE NOTES
FOR BASIC NURSING
 TABLE OF CONTENTS
BASIC NURSING................................................................................................................................................4
INTRODUCTION................................................................................................................................................4
COURSE DESCRIPTION.......................................................................................................................................4
Course Objectives..........................................................................................................................................4
CHAPTER 1.......................................................................................................................................................5
1.0 PRINCIPLES OF BODY MECHANICS AND ITS APPLICATION IN NURSING......................................................5
Body mechanics and positions used in nursing patients................................................................................5
Use of appropriate gadgets in lifting and changing patients position in bed.................................................7
CHAPTER 2:......................................................................................................................................................8
2.0 BASIC NURSING PROCEDURES.....................................................................................................................8
CHAPTER 3:....................................................................................................................................................78
3.0 PRINCIPLES OF ASEPSIS..............................................................................................................................78
MEDICAL ASEPSIS.............................................................................................................................................78
SURGICAL ASEPSIS...........................................................................................................................................80
CHAPTER 4.....................................................................................................................................................82
4.0 BASIC CONCEPTS OF HOMEOSTASIS..........................................................................................................82
Components.................................................................................................................................................82
A receptor....................................................................................................................................................82
Control Centers............................................................................................................................................83
The Effectors................................................................................................................................................83
Homeostatic Mechanisms............................................................................................................................83
Physiology Of Homeostasis In Relation To Health........................................................................................83
Homeostatic Disorders.................................................................................................................................84
CHAPTER 5.....................................................................................................................................................85
5.0 BASIC PRINCIPLES UNDERLYING HEALTH AND DISEASE IN NURSING CARE...............................................85
Introduction to nursing process...................................................................................................................85
Phases Of Nursing Process...........................................................................................................................85
Assessment Skills.........................................................................................................................................86
Nursing Diagnosis.........................................................................................................................................87
Outcome criteria/ identification..................................................................................................................87
Implementation...........................................................................................................................................87

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 Admission, transfer, and discharge..............................................................................................................88
Types Of Admission......................................................................................................................................89
Discharging The Patient...............................................................................................................................90
Discharging A Patient From The Hospital...................................................................................................90
Rehabilitation and Continuity of Care..........................................................................................................91
CHAPTER 6.....................................................................................................................................................92
6.0 DOCUMENTATION AND ITS LEGAL IMPLICATIONS IN NURSING PRACTICE................................................92
Purpose of documentation..........................................................................................................................92
Principles Of Nursing Documentations........................................................................................................93
Documentation Format................................................................................................................................94
Types Of Records.........................................................................................................................................94
Reporting.....................................................................................................................................................95
Legal Implications of Documentation..........................................................................................................95
CHAPTER 7.....................................................................................................................................................96
7.0 PAIN ASSESSMENT AND MANAGEMENT....................................................................................................96
Types Of Pain...............................................................................................................................................96
Factors Influencing Pain...............................................................................................................................97
Guidelines On Pain Assessment...................................................................................................................97
Common Pain Scales....................................................................................................................................98
Pain Management........................................................................................................................................99
CHAPTER 8.....................................................................................................................................................99
8.0 BASIC PRINCIPLES OF WOUND DRESSING..................................................................................................99
Precautions To Be Taken Before Wound Dressing.....................................................................................100
Dressing Of Wound In The Ward...............................................................................................................100
A Dressing Pack Containing........................................................................................................................100
Wound dressing without an assistant........................................................................................................101
Wound Dressing with An Assistant............................................................................................................101
CHAPTER 9....................................................................................................................................................102
9.0 ADMINISTRATION OF MEDICATION.........................................................................................................102
Medication.................................................................................................................................................102
Rules For The Administration Of Drugs....................................................................................................104
Route Of Administration............................................................................................................................105
Administration of liquid medication and mixtures.....................................................................................106
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 Administration Of Tablets..........................................................................................................................107
Injection.....................................................................................................................................................107
Abbreviations Used In Prescription............................................................................................................111
Dangerous Drugs Act.................................................................................................................................112
CHAPTER 10..................................................................................................................................................113
SKILLS TO MEET SUPPORTIVE NEEDS OF THE DYING.....................................................................................113
Last Offices.................................................................................................................................................114
Care Of The Body After Death....................................................................................................................114
Preparation Of the Body............................................................................................................................115
CHAPTER 11..................................................................................................................................................116
GRIEF AND THE GRIEVING PROCESS..............................................................................................................116
TYPES OF GRIEF..........................................................................................................................................117
Anticipatory grief.......................................................................................................................................117
Disenfranchised Grief.................................................................................................................................117
Complicated Grief......................................................................................................................................117
Collective Grief...........................................................................................................................................118
Cumulative Grief........................................................................................................................................118
STAGES OF GRIEVING.................................................................................................................................118
What to do to help the griever..................................................................................................................120

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 BASIC NURSING

INTRODUCTION
COURSE DESCRIPTION
This course is designed to enable the student to apply the principles of body mechanics and its
application in nursing care, perform basic nursing procedures, demonstrate the principles of
sepsis, and apply basic concepts of homeostasis as well as principles underlying health and
disease in nursing care. The course will also highlight the legal implications in nursing and
midwifery practice, pain assessment and management, basic principles of wound dressing and
administration of medications. Emphasis will be laid on the use of the nursing process to meet
the supportive needs of the dying and support during the grieving process.

Course Objectives
By the end of the course, the student will be able to:

a. apply the principles of body mechanics and its application in nursing care
b. perform basic nursing procedures
c. demonstrate the principles of asepsis
d. apply basic concepts of homeostasis in the care of individual
e. apply basic principles underlying health and disease to give necessary care using the
nursing process
f. understand documentation and its legal implications in nursing and midwifery practice
g. discuss pain assessment and management
h. perform basic principles of wound dressing
i. administer medications
j. develop skills to meet supportive needs of the dying
k. provide appropriate support during the grieving process for patients and relatives

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 CHAPTER 1
1.0 PRINCIPLES OF BODY MECHANICS AND ITS APPLICATION
IN NURSING

A. BODY MECHANICS AND POSITIONS USED IN NURSING PATIENTS

Body mechanics involves the coordinated effort of muscles, bones, and nervous system to
maintain balance, posture, and alignment during moving, transferring, and positioning patients.
Proper body mechanics allows individuals to carry out activities without excessive use of
energy and helps prevent injuries for patients and health care providers.
Musculoskeletal injuries
A musculoskeletal injury (MSI) is an injury or disorder of the muscles, tendons, ligaments,
joints or nerves, blood vessels or related soft tissue including a sprain or inflammation related
to a work injury. They are the most common health hazard for health care providers.

The table below lists risk factors that contribute to an MSI.

Factor Special information

Ergonomic risk factors Repetitive or sustained awkward postures,
repetition, or forceful exertion
Individual risk factors Poor work practice; poor overall health (smoking,
drinking alcohol and obesity); poor rest and
recovery; poor fitness, hydration, and nutrition

Preventing an MSI is achieved by understanding the elements of body mechanics, applying the
principles of body mechanics to all work-related activities, understanding how to assess a
patient’s ability to position or transfer and learning safe handling transfers and positioning
techniques.

Elements of body mechanics

Body movement requires coordinated muscle activity and neurological integration. It involves
the basic elements of body alignment (posture), balance and coordinated movement. Body
alignment and posture bring body parts into position to promote optimal balance and function.
When the body is well aligned, whether standing, sitting, or lying, the strain on the joints,
muscles, tendons, and ligaments is minimized.
Body alignment is achieved by placing one body part in line with another body part in a
vertical or horizontal line. In the language of body mechanics, the center of gravity is the center
of the weight of an object or person.

Guidelines of proper body mechanics

 Bend at your hips and knees instead of your waist
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 This helps you maintain your balance by dividing your weight evenly between your upper and
lower body.

 Spread your feet apart to create a foundation of support.

This helps you maintain your balance from side to side.
 Keep your back, neck, pelvis, and feet aligned when you turn or move.
Do not twist or bend at your waist.

B. How to practice proper body mechanics

 When you stand:
1. Keep your feet flat on the floor about 12inches (30cm) apart.
2. Do not lock your knees
3. Keep your shoulders down, chest out and back straight.

 When you lift an object:

1. Your feet should be apart, with one foot slightly in front of the other.
2. Keep your back straight
3. Bend from your hips and knees
4. Do not bend at your waist
5. Lift the object using your arm and leg muscles
6. Hold the object close to your body at waist level
7. Use the same process if you need to push or pull something heavy.

 When you sit

1. Sit with your back straight and place extra support behind your lower back.
2. Get up and change positions often if you sit for long periods of time.
3. Ask about exercises to stretch your neck and shoulders
4. Adjust your computer so the top of the monitor is at the level as the eyes.

 Wear shoes with low heels, closed backs and nonslip soles.
This will help prevent falling and improve your body alignment.

 Pull rather than push an object

This is to prevent strain on your back muscles. The muscles you use to pull are stronger
than those you use to push.

 Ask for help or use an available device for assistance. Assistive or mechanical devices help
decrease your risk for injury.

Importance of proper use of body mechanics

1. Is to prevent injuries to both patient and provider.
2. It helps employees experience a much better quality of life.

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 3. It helps employees to be acutely aware of their bodies and movements to begin making
improvements.

C. Use of appropriate gadgets in lifting and changing patients position in bed

The proper use of equipment is essential for the safety of both clients and care givers and improves
the quality of client care. Equipment can also facilitate client rehabilitation, decrease morbidity,
and preserve the dignity of clients. Compared with techniques that involve manual transfers of
clients without equipment, the use of equipment lessens the forces required for moving and
handling clients and can reduce risks.
Moving and handling equipment also improves client outcomes such as reducing their length of
stay and the risk of complications such as chest infections, falls, pressure ulcers
Types of equipment/ gadgets

Type of equipment Description and common uses

Slide sheet A sheet made of low friction material and
used under a client to allow easy
repositioning in bed, sling attachment and
lateral transfers
Transfer belt (handling belt, gait, and walking A belt placed around a client’s waist during
belt) several types of transfer and for assisted
walking for rehabilitation.
Transfer board A full body length board made from wood or
plastic used to bridge gaps for client’s
transfers from one surface to another such as
from stretcher or wheel chair to a bed.
Smaller transfer boards can also be used for
lateral, seated-to- seated transfers.
Electric profiling bed An electrically operated bed that has a
mattress platform split into two, three or four
sections which allow adjustment using a
control handset
Mobile hoist A hoist with wheels that can be moved along
the floor- used for lifting a client inside a
sling or a stretcher
Standing hoist A specific type of mobile hoist designed to
assist people between sitting and standing
positions. They are designed to fit under and
around chairs
Ceiling hoist A hoist attached to permanently

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 CHAPTER 2
2.0 BASIC NURSING PROCEDURES

A. POSITIONS USED IN NURSING PATIENTS

Patient positioning involves properly maintaining a patient’s neutral body alignment by preventing
hyperextension and extreme lateral rotation to prevent complications of immobility and injury.
Positioning patients is an essential aspect of nursing practice and a responsibility of the nurse in
surgery, specimen collection and other treatments.

Goals of patient positioning

The goal of proper patient positioning is to safeguard the patient from injury and physiological
complications of immobility.
Goals include:

 Provide patient comfort and safety: support the patient’s airway and maintain the circulation
throughout the procedure eg in surgery, specimen collection and in so doing it will prevent
nerve damage and unnecessary extension or rotation of the body.
 Maintaining patient dignity and privacy: in surgery or specimen collection proper
positioning of patient is a way of respect and minimizing exposure of patient.
 Allows maximum visibility and access: proper positioning allows ease of surgical access as
well as anesthetics and specimen collection procedures.
Guidelines for patient positioning
Proper execution is needed during patient positioning to prevent injury for both the patient and
the nurse. Guidelines used include:
1. Explain the procedure: provide explanation to the client on why his or her position is being
changed and how it will be done. Rapport with the patient will make them more likely to
maintain the new position.
2. Encourage client to assist as much as possible: determine if the client can fully or partially
assist. Clients that can assist will save strain on the nurse and it will also be a form of
exercise, increase independence and self-esteem of the client.
3. Get adequate help: when planning to move or reposition the client, ask help from other
caregivers.
4. Use mechanical aids: bed boards, slide boards, pillows can facilitate ease of changing
positions.
5. Raise client’s bed: adjust or reposition the client’s bed so that the weight is the level of the
nurse’s center of gravity.

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6. Frequent position changes: note that any position correct or incorrect can be detrimental to
the patient if maintained for a long period. Repositioning patient every 2hours helps prevent
complications like pressure ulcers.
7. Avoid friction and break down of skin: when moving patients, lift rather than slide to
prevent friction that can lead to skin damage.
8. Proper body mechanics: observe good body mechanics for you and your patient’s safety.

Common Patient Positions

The following are the commonly used patient positions used
I. Supine or dorsal recumbent position

Supine Dorsal Recumbent

 Is when the patient lies flat on the back with head and shoulders slightly elevated using a
pillow unless contraindicated eg spinal surgery.
 In supine position legs maybe extended or slightly bent with arms up or down. It provides
comfort in general for patients under recovery after surgery.
 Supine position is used for general examination or physical assessment.
 Supine position may put patients at risk for pressure ulcers and nerve damage. Assess for
skin breakdown and pad bony prominences.
 Small pillows maybe placed under the head and heels must be protected from pressure by
using pillows or ankle roll. Place a padded footboard to prevent plantar flexion and stretch
injury to the feet.

II. Fowler’s position

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  Also known as semi-sitting position, is a bed position where the head of the bed is
elevated 45 to 60 degrees. Variations of fowler’s position include:
1. Low fowler’s (15-30 degrees)
2. Semi- fowler’s (30-45 degrees)
3. High fowler’s (nearly vertical)
 It is also used for patient having difficulty in breathing
 Also used for patient who have nasogastric tube in position/ place
 It can also be used for patients who are being prepared to start walking.
 Fowler’s position is also used in some surgeries that involves the shoulders or
neurosurgery.
 To prevent foot drop in fowler’s position, footboard must be used to keep the patient
feet in proper position.

III. Orthopneic or tripod position

 In this type of position, the patient is placed in a

sitting position or on the side of the bed with an
over bed table in front to lean on and several
pillows on the table to rest on.
 It helps in the maximum expansion of the lungs
and mostly used for patient having difficulty in
breathing
 It also helps in exhaling because the lower part of
the chest is pressed against the edge of the over bed
table.

IV. Prone position

Prone Semi-prone (recovery)

 The patient lies on the abdomen with head turned to one side and the hips are not
flexed.
 Extension of hips and knee joint helps to prevent flexion contractures of the hips and
knees. Prone position is the only bed position that allows full extension of the hip and
knee joints.

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  It is contraindicated for patients with spinal problems and can only be used when
patient back is aligned.
 It is mostly used for neurosurgery in most neck and spine surgeries.
 To support a patient lying in prone, place a pillow under the head and a small pillow or
a towel roll under the abdomen.
 It also promotes drainage from the mouth and useful for clients who are unconscious or
those recovering from mouth or throat surgery.

V. Lateral position

Left lateral Right lateral

In lateral or side-lying position, the patient lies on one side of the body with the top leg in front
of the bottom leg and the hip and knee flexed. Flexing the top hip and knee and placing this leg
in front of the body creates a wider, triangular base of support and achieves greater stability.
This flexion reduces lordosis and promotes good back alignment.

 Lateral position helps relieve pressure on the sacrum and heels especially for people
who sit or are confined to bed rest in supine or fowler’s position.
 To correctly position the patient in lateral position, use of support pillows are needed.
 In this position, most of the body weight is distributed.

VI. Sims’ position

Sims’ position or semi prone position is when the patient assumes a posture halfway between
the lateral and the prone positions. The lower arm is positioned behind the client, and the upper
arm is flexed at the shoulder and the elbow. The upper leg is more acutely flexed at both the hip
and the knee than is the lower one.
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  Sims’ may be used for unconscious clients because it facilitates drainage from the
mouth and prevents aspiration of fluids.
 It is also used for clients receiving enemas and occasionally for clients undergoing
examinations or treatments of the perineal area.
 Is a comfortable position used by pregnant women `for sleeping.
 Sims’ position support proper body alignment by placing a pillow underneath the
patient’s head and under the upper arm to prevent internal rotation and another
pillow between legs.

VII. Lithotomy position

Lithotomy is a patient position in which the patient is on their back with hips and knees flexed
and thighs apart.
Lithotomy position is commonly used for vaginal examinations and childbirth.
It can be classified as low, high, standard, hemi and exaggerated lithotomy positions.

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  Low lithotomy position is where the patient hips are
flexed until the angle between the posterior surface
of the patient’s thigh and the OR bed surface is 40
to 60 degrees. The patient’s lower leg is parallel
with the bed.
 Standard lithotomy position: the patient hips are
flexed until the angle between the posterior surface
of the patient’s thighs and the bed surface is 80 to
100 degrees.
 Hemi lithotomy position: the patient’s non-
operative leg is positioned in standard lithotomy.
The patient’s operative leg maybe placed in
traction.
 High lithotomy position: the patient’s hips are
flexed until the angle between the posterior surface
of the patient’s thighs and the bed surface is 110 to
120 degrees. The patient’s lower legs are flexed.
 Exaggerated lithotomy position: the patient’s hips
are flexed until the angle between the posterior
surface of the patient’s thigh and bed surface is 130
to 150 degrees. The patient’s legs are almost

VIII. Trendelenburg’s position

Involves lowering the head of the bed and raising the foot of the bed and raising the foot of the
bed of the patient. The patient’s arms should be tucked at their sides.

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  It promotes venous return and hypertensive patients benefits from this position.

IX. Reverse Trendelenburg’s position

Is a patient position wherein the head of the bed is elevated with the foot of the bed down. It is
the opposite of Trendelenburg’s position.

 It prevents esophageal reflux by emptying the stomach and prevents reflux for clients
with hiatal hernia.

X. Knee-chest position

Can be in lateral or prone position.

In lateral knee-chest position, the patient lies on their side, lies diagonally across the table, hips
and knees flexed.
In prone knee-chest position the patient kneels on the table and lower shoulders on the table so
chest and face resets on the table.

 Usual position adopted for sigmoidoscopy without anesthesia.

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  Prone knee-chest position can be embarrassing for some patients.
 Knee-chest position is assumed for a gynecologic or rectal examination.

XI. Jackknife position

Also known as Kraske where the patient’s abdomen lies flat on the bed. The bed is scissored so
the hip is lifted, and the legs and head are low.

 Is frequently used for surgeries involving the anus, rectum, coccyx, and certain back
surgeries.
 Many pillows are required on the operating table to support the body and reduce
pressure on the pelvis, back and abdomen. Jackknife position also puts excessive
pressure on the knees so while positioning surgical staff should put extra padding for
the knee area.

Support Devices For Patient Positioning

The following are the devices or apparatus that can be used to help position the patient properly

 Bed boards
They are plywood boards that are placed under the entire surface area of the mattress
and are useful for increasing back support and body alignment.

 Foot boots
They are shoes made of rigid plastic or heavy foam and keep the foot flexed at the
proper angle. It is recommended that they should be removed 2 to 3 times a day to
assess the skin integrity and joint mobility.

 Hand rolls
It maintains the fingers in a slightly flexed and functional position and keep the thumb
slightly adducted in opposition to the fingers.

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 Pillows
They provide support, elevate body parts, splint incision areas, and reduce postoperative
pain during activity, coughing or deep breathing. They should be of appropriate sizes
for the body to be positioned.

 Sandbags
Are soft devices filled with substance that can be used to shape or contour to body’s
shape and provide support. They immobilize extremities and maintains specific body
alignment.

 Side rails
They are bars along the sides of the length of the bed. They ensure client safety and are
useful for increasing mobility. Side rails also provide assistance in rolling from side to
side or sitting up in bed. They are used to prevent patient from falling from the bed and
used also in caring for aggressive and confused patient.

B. BED MAKING

Bed making is an essential procedure in nursing in which nurses prepare and arrange different
types of beds for client’s comfort in the hospital or other health care institutions.
Bed making procedure ensures the patient’s comfort according to the situation, it may vary on
the client’s conditions, purposes, and procedures such as occupied, unoccupied, cardiac,
fracture, admission, operation etc.
Nurses have a major role in bed making procedure in hospital. So, a nurse should learn and
follow the proper and standard techniques of bed making procedures.
Bed making is a technique in which different types of beds are prepared to make a client or
patient comfortable according to the situations and procedures.

Purposes of making bed

1. Bed making helps the bed and patient’s unit look tidy.
2. Bed making removes the dirt and germs from patient’s bed.
3. Bed making enhances the esthetic looks of the patient’s unit.
4. To prevent bed sores
5. To establish interpersonal relationship
6. To keep it ready for any emergencies
7. To receive patient comfortably
Principles of bed making

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 Micro-organisms are present everywhere, on the used articles, skin, clothing, and environment.
Prevent the spread of micro-organisms from the contaminated source to the new host.
Action
1. The nurse should wash the hands before and after the bed making procedure to prevent
cross infection.
2. Bed linen and clothes must be changed frequently to ensure cleanliness.
3. Do not drop the removed bed linen on the floor.
4. Gently shake the linen to remove dust. Do not flap the bed clothing because it transfers
dust and bacteria easily.
5. Linen should be folded and held away from the nurses to prevent direct contact with
dust and micro-organisms.
6. Nurse having respiratory infections should not attend to clients.
7. Linens should be disinfected before sending them to the laundry.
8. Nurse should maintain a necessary distance from patient to prevent droplet infection.
9. Damp dusting is recommended because dry dusting raises dust.
10. Clean the less contaminated area first before high contaminated area to minimize the
spreading of micro-organisms to the clean area.

 Maintaining good body mechanisms prevents fatigue and align the body

Action
1. Flex the knees and the hips when tucking the sheet under the mattress. This position
shifts the work to the and strong muscle of the thigh and keeps the back in good
alignment.
2. When placing and tucking the linen, face the direction of the work and move with the
work rather than twisting the body and overreaching.
3. In standing position, the nurse can have a wide base by separating his/her feet and in
doing this stability of the body is assured.

 A protected and comfortable bed will provide rest, sleep and avoid many complications of
bedridden client’s e. g. bedsores, foot drop etc.

Action
1. Nurse should make a smooth and unwrinkled bed because a wrinkled bed exerts
pressure on bony prominence. The wrinkles cause bedsores due to friction between skin
and wrinkled sheets.
2. Do not keep wet linen on the bed.
3. A bed should have enough space to move from side to side. The movements prevent
bedsores, stimulates blood circulation, and maintain muscle tone.
4. Use comfortable devices to provide additional comfort to the client.
5. Tuck the linen far enough and tightly to keep it fixed.
6. Pull the bottom sheet tightly to prevent wrinkles.
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 Planned and organized ways of working saves energy, time, and equipment

Action
1. Collect and arrange all the articles before starting the bed making procedure.
2. Fold bed sheets in such a way that they can be replaced easily.
3. Remove the bed linen one by one holding the open end towards the floor when stripping
the bed so that the client’s possessions and the hospital articles are not to the laundry.

General Instructions For Bed Making In Hospital

 Wash hands properly before and after the procedure.
 Do not expose the client unnecessarily
 Do not keep clean linen with soiled linen.
 Always ensure that the client do not lie down on the mackintosh without linen.
 Shake the linen gently
 Maintain a distance so that the linen should not touch your body or uniform.
 Any conversation during the bed making should be include only the patient but not the
nurses’ personal matters.
 The patient face must not be covered by sheets or blankets.
 Always maintain good body mechanics so as prevent extra workload.
 Make a bed comfortable, smooth, and unwrinkled.
 To prevent cross-infection maintain reasonable distance with the patient.
 All requirements should be collected before starting.
 Two nurses are required, and they work in harmony.
 Extra assistance should be available and if necessary, should be called upon to help to
lift the patient.
 When pillows are being shaken the nurse should turn away from the client.

Requirements needed for bed making

o Cot or bed
o Mattress
o Pillow
o Chair or stool
o Bedside table
o Mackintosh (long and short)
o Blanket
o Mattress cover
o Top sheet
o Bottom sheet
o Draw sheet
o Pillowcase
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 o Counterpane
o Laundry basket
o Duster

Types of beds
We have two types of beds
1. Simple beds: They include unoccupied and occupied beds
2. Special beds: They include admission, operation, fracture, cardiac beds, and amputation
beds.

Making An Unoccupied Bed

An unoccupied bed is a type of bed that does not have a patient in it.
Requirements:

- A trolley with the following

- Two large cotton sheets
- One waterproof draw mackintosh (if necessary)
- One draw sheet
- One pillow or two
- Pillow covers
- One blanket optional
- One bed cover or counterpane

Procedure
 The above articles should be collected and put over two chairs placed back-to-back at
the bottom of the bed.
 Place long mackintosh on mattress if necessary
 Place bottom sheet evenly on the bed
 Tuck the sheets under the mattress using enveloped corners starting from the top
 Pull sheet tight so that there are no creases
 Place a draw mackintosh across the bed with the upper corner under the edge of the
pillow.
 Cover mackintosh with draw sheets and tuck it in.
 Place the pillow on the bed with the open ends of the slip are away from the door.
 Place top sheet on with the wrong side uppermost.
 Fold over about twenty inches of the sheet at the top.
 The sheet is loosely tucked in at the bottom to prevent restriction of the feet.
 Place the counterpane loosely over the sheet.
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  Tuck in the bottom end of the bed using envelope corner.
 Fold top sheet over the counterpane with the sides tucked under the mattress
 After bed making the nurse must make sure that all the locker (bed side) and the two
chairs used have been replaced in their proper positions.
 Remove trolley.

How To Make Simple Occupied Bed

Simple occupied bed is a type of hospital bed with a patient in it.

Requirements
Extra requirement in addition to simple unoccupied bed is dirty linen bin.
Methods
We have:
1. Side to side
2. Top to bottom
Procedures/ steps
 Explain procedure to patient if he/she is conscious
 Provide privacy by placing a screen across the ward door (routine bed making)
 Note that if routine bed making is not in progress the individual bed is screened.
 Place two chairs at the foot end of the bed
 Untuck the bed clothes beginning from the top
 Remove counterpane or blanket if present by folding it into three parts on to the chair
 Do not expose patient
 Remove all pillows and other bed accessories where necessary and depending on patient’s
condition.
 If side to side method is employed
 Roll the patient gently from side to side and support him or her in this position (lateral
position) that is why two nurses, or more are needed to do this procedure.
 Roll bottom sheet, draw sheet and mackintosh up to the patient’s back.
 Turn patient to the other side and remove soiled linen and then pull the clean one and tuck
in well free from crumbles.
 If top to bottom method is employed
 Lift patient to the bottom of the bed and remove soiled linens
 Place clean ones by rolling it to the back of the patient while’s one nurse is supporting
patient.
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 Replace pillows and other bed accessories
 Replace top sheets and counterpane and leave patient comfortable
 Discard trolley.
Note: clean patient if he/she has soiled him/herself before putting the clean sheets.
The bed clothes should not be tucked in too tightly around the patient, particularly over the feet.
There should be freedom to move.

Special Appliances/Accessories Used In Bed Making

Bed accessories are equipment and articles used in making special types of beds and used for
offering care to patients in bed.
1. Hot water bottle

This is a rubber bottle filled with hot water to provide

warmth to the patient. Always inspect for holes and pricks
before filling and make sure to get them fixed if any. After
every use empty the hot water bottle and dry.

2. Bed cradles

These are wooden or metal frames used to lift weight of

bed clothes from the patient. It is also used for drying
plaster of Paris (P.O.P), viewing of parts of the body
example bleeding stump after amputation.

3. Elbow or heel ring

21
 This is a small ring, similar to the one
used in preventing pressure sores.

4. Mackintosh or waterproof sheet

Is a waterproof material put either on a mattress to protect the

bottom sheet from soiling or wetting. Example in cases of
incontinence or during vaginal examination. It is also used to
protect pillows in cases of bleeding and vomiting.
When it is stained with discharge or blood immerse it in
parazone for 10minutes, take it out and wash with soap and
water. You can also mob dry or hang to dry. After drying you
can powder, roll and store for the next use.

5. Water or air beds

This is a type of mattress made of waterproof sheet
filled with water or air. It is put on the bed to
prevent pressure sores especially in emaciated or
paralyzed patients. If stained with blood or
discharges, deflate the bed and decontaminate with
parazone, wash with soap and water. Dry, powder
and store or inflate ready for use.

6. Sand bags
This is a strong thick material of various shapes and
sizes filled with smooth sand and is used to maintain
the position of a patient. When dirty open up the bag
and empty completely and wash with soap and
water. Dry, iron and refill with smooth sand. Sew
end firmly and keep in cupboard ready for next use.

7. Bed / heart/ cardiac table

22
 It is made of metal or wood put in front of
patients for meals, medications or with pillows
for patient to lean forward on to ease difficulty in
breathing. Clean with savlon, dry and oil wheels
if necessary.

8. Bed rest
It is a type of wooden or metal adjustable
framework or bed attachment used in helping
patient sit upright in bed. Example to ease
difficulty in breathing.

9. Footrest
It is a small piece of wood fitted at the foot end
of the bed to support the feet in order to
prevent foot drop.

10. Fracture boards

These are boards which fits across the springs of
the bed and are used to prevent the mattress from
sagging. They are used in the treatment of some
fractures and back injuries.

23
Types Of Special Beds
1. Admission beds
It is a specially made bed for patients who are admitted into the ward. It is made in such a way
that a patient or client is admitted without delay.
Purpose
1. To provide warmth for the patient.
2. To allow immediate admission.
3. To facilitate bathing of patient in bed without undue disturbance.
4. To give prompt treatment.
Requirements
Extra requirements to be added to those for simple unoccupied bed.
A trolley with the following items:

 Long mackintosh sheet or mackintosh if necessary

 One or two blankets if necessary
 Bed accessories depending on patient’s condition eg bed blocks or elevator, bed cradle,
bed rest.
Steps
o Make up bed as for simple unoccupied bed until draw sheet or mackintosh is in position.
o Cover with long mackintosh or waterproof sheet if necessary.
o Use one bath blanket or sheet over the waterproof sheet and tuck in all around or fold
under itself.
o Place second bath blanket over the bed.
o Put in hot water bottles if necessary.
o Put on top clothes.
o Place counterpane loosely over the top bed clothes.
o Tuck in the bed clothes on other side.
o Fold the bedclothes over the side nearest to the door, leaving it open to facilitate quick
admittance.

2. Operation bed
It is a type of bed that is made ready to receive a patient returning from operating theatre.
Purpose

 To provide warmth
 To receive patient from theatre

24
  To combat shock
 To protect linen from vomit and saliva.

To clear mouth of any saliva for which purpose a tray is set.

Requirements
Extra requirements to be added to those required for a simple unoccupied bed.
o Mackintosh or any waterproof material and or dressing towel
o One or more blanket if necessary
o Bed accessories to suit patient’s condition
o Drip stand
o Post anesthetic tray by the bed side containing the following:
o Vomit bowl
o Dressing towel
o Kidney dish containing swab holding forceps, dissecting forceps, tongue holding
forceps, spatula.
o A gallipot with gauze swabs
o An injection tray
o Mouth gag
o A receiver for soiled swabs
o A gallipot with cold water
o A receiver to receive mouth wash
o Temperature, pulse, and respiration tray
o Blood pressure apparatus
o Charts for recording

Steps/procedure
1. Make up simple unoccupied bed until draw sheet is in position.
2. Place waterproof and dressing towel a top of bed.
3. Leave pillow on chair
4. Place hot water bottle on bed if necessary
5. Place blanket on bed if necessary
6. Put top clothes on as for admission
7. Turn back the bottom end of the clothes.
8. Fold the top clothes at the open side and three parts over the bed for easy admission of
the patient.
Note: remove hot water bottle before patient is put in bed.

25
3. Cardiac bed
Is a type of bed that is mainly arranged in such a way that the patient is kept in a sitting position
on the bed with the help of pillows and a cardiac table, it relieves the patient from the problem
caused by heart disease and specially made for patient who have heart problems.
Purpose

 To make the patient as comfortable as possible when sitting upright.

 To relieve dyspnea caused by cardiac disease
 To prevent complications caused by cardiac disease

Requirements
o Articles of simple bed including extra items
o Backrest used to support the patient while sitting
o Cardiac table to provide support and comfort
o Footrest to slipping down
o Air ring in a cotton cover to relieve pressure
o Extra pillows to provide support and comfort
o A bell
o A paper to write if the patient is literate.

Procedure
1. Prepare bed same as the open bed
2. The back rest is placed in position at the top of the bed and arranges the pillows behind
the patient as necessary
3. Put the air ring in position
4. Place the knee pillows under the knees
5. Arrange the pillows on either side of the arms
6. Cover the patient with the top clothes if necessary
7. Adjust the cardiac table with the pillow in front of the client so that the client can lean
forward and rest on it.
8. Place a bell on the cardiac table and a paper and pen on it

4. Fracture bed
Is a bed which is used for a patient with fracture of the truck or extremities to provide a firm
support by using a firm mattress that rest on the bed board. it is mostly used to dry a Plaster of
Paris splint or cast as quickly as possible.

26
Purpose

 To provide a strong unyielding foundation for the patient

 To prevent movement of the fracture bone especially in spinal fracture and fracture of
the skull bone.
Requirements in addition to those required for a simple bed
o Fracture board
o A flannelette sheet and woolen sock
o Waterproof and dressing towels
o Protected pillow
o Bed cradle

Steps
1. Make bed as for a simple bed until the draw sheet is in position
2. Place fracture board under the mattress to provide firm support and prevent sagging
3. Put bed accessories in position if necessary
4. Place top sheet/clothes in position and tuck them in neatly.

5. Amputation bed
Is a bed in which the top linen is divided into two parts to visualize the amputated part of the
lower limbs without disturbing the patient.

Purpose

 To provide a comfortable position and keep the stump in an appropriate position.

 To be able to watch the stump for hemorrhage and apply a tourniquet instantly if necessary
 To allow the health care worker to make frequent observations for caring for a patient
without disturbing the patient after amputation of the leg.
 To carry the load of the patient’s bed linen to protect the patient from the load of clothing.

Requirements
o Articles of simple bed including extra items
o Extra set of top linens to make a divided bed
o Blankets and counterpane
o Bed cradle to keep the weight of bed clothes from pressing over the part.
o Tourniquet and dressing tray to control hemorrhage in case of emergency
o Pillow with waterproof /plastic cover to elevate the stump and protect the pillow
o Sandbags to keep the stump in position
27
 Procedure
 Prepare the bed as for a simple bed until the draw sheet is in position.
 The top sheet is placed over the patient’s chest, truck, and good leg
 The waterproof and dressing towels are placed where the stump will lie.
 The narrow mackintosh and narrow sheet are placed over the thigh and held firmly
placing the sandbags over it at either side of the thigh. This is done to protect the linen
and sandbags and to immobilize the painful joints.
 Cradle is then placed over the stump
 The top sheets in two parts maybe folded slightly back and they should overlap at each
other, and this is done to unable proper observation of the stump and to prevent also
unnecessary exposure of patient.
 The tourniquet on a tray with dressing towel to protect the limb should be near at hand
but out of view of the patient.

C. OBSERVATION AND RECORDING OF VITAL SIGNS

Vital signs are measurements of the body’s most basic functions. The four main vital signs
routinely monitored by medical professionals and health care providers include the following
1. Body temperature
2. Pulse rate
3. Respiration rate (rate of breathing)
4. Blood pressure
Vital signs are useful in detecting or monitoring medical problems. It reveals also changes in
patient emotional state if there is significant variation in the findings.
It also reveals some information which help in the diagnosis of diseases resulting in treatment,
medication, and nursing care.
1. Body temperature
Temperature is the specific degree of hotness or coldness of the body. It can also be defined as
a measure of how well your body can make and get rid of heat. It is checked with a
thermometer.
When the body is too hot the blood vessels in your skin widen to carry the excess heat to your
skin’s surface and you may start to sweat. As the sweat evaporates it helps cool the body.
When the body is cold, blood vessels narrow. This reduces blood flow to your skin to save
body heat and this can result in shivering. When the muscles tremble this way, it helps to make
more heat.

28
 Variation in body temperature
Temperature ranges

 Collapse temperature- below 350C

 Subnormal temperature- 35.2-36.20C
 Normal temperature – 36.2- 37.20C
 Pyrexia – above 37.20C
Low – 37.2- 38.30C
Moderate – 38.3- 39.40C
High – 39.4- 40.50C
 Hyperpyrexia- over 40.50C

The most common sites on the body where temperature can be measured are:
a. The mouth
b. The groin
c. The rectum
d. The axilla
e. Sometimes the forehead
Body temperature is either measured in degrees Fahrenheit ( 0F) or degrees Celsius (0C) or
centigrade.
How to convert temperatures
 Converting from Fahrenheit to Celsius or centigrade
5
Subtract 32 from the Fahrenheit then multiply by that is if example 0F is 98.6 then
9
5
(98.6-32) x = 370C
9

 Converting from 0C to 0F
9
Multiply and add 32 to the temperature
5
9
(37 x ) + 32 = 98.60F
5

Types of Thermometers
a. Lotion thermometer
b. Bath thermometer
29
 c. Clinical thermometer
d. Electronic thermometer
e. Wall thermometer
Taking temperature using a clinical thermometer by the axillary/ groin method
Requirements
A tray containing
o Clinical thermometer
o Gallipot containing clean cotton wool swabs
o Receiver for used swabs
o Gallipot containing water for rinsing the thermometer
o A watch seconds hand
o Temperature chart
o Pen

Steps/ procedure
1. Explain procedure to patient
2. Provide privacy
3. Take temperature tray to patient bed side
4. Make patient comfortable by lying or sitting up in bed
5. Remove the thermometer from the test tube, rinse it in cold water and dry it with cotton
wool swab and also examine the thermometer for any cracks
6. Clean the groin or the axilla of patient and also clean the thermometer from the tip of the
bulb to the stem.
7. Shake the thermometer to bring the mercury to 350C
8. Insert the thermometer in the axilla/ groin making sure the bulb is in between skin folds
9. Leave thermometer in situ for 2-3minutes
10. Remove, wipe from the stem towards the bulb and check reading, hold it to eye level and
rotate in between the fingers until the mercury line is clearly visible to read
11. Record the reading on the temperature chart
12. Thank patient and leave patient comfortable
13. Discard tray and wash hands
14. Document all findings in the nurse’s note and report any abnormality.
15. Note that axilla/ groin temperature should be taken within 30minutes of bathing.

Taking Oral Temperature

The requirement is the same as the groin/axilla and the procedure too is the same. The
difference is the position of the thermometer. In the oral temperature the thermometer is placed
under the patient’s tongue and advice to close the lips tight but not to bite on the thermometer.
30
The patient is also advised not to speak whiles the thermometer is in situ and also each patient
should be provided with an individual thermometer. Note that oral temperature should not be
taken immediately patient has had a hot or a cold drink.
Contraindications in using the oral temperature include
a. A patient who has his/her nose packed with gauze and cannot breathe
b. Patients having fits or liable to have it
c. Patients having conditions of the mouth
d. Unconscious patients
e. A confused and disoriented patient
f. Children under six years of age
Taking rectal temperature
It is checked using a special rectal thermometer which is shorter and has a thick bulb and each
patient should his/her thermometer. In addition to the requirements a petroleum jelly is added
and is mostly used in babies and children. It is mostly used for adults in special cases.
To take rectal temperature of an adult
1. Explain procedure to patient and ask for cooperation because is uncomfortable
2. Provide privacy
3. Prepare and send tray to the bed side
4. The patient should lie in the left lateral position and the clothes removed and covered with
one blanket.
5. The thermometer is removed, checked, rinsed and cleaned and then lubricated
6. It is then inserted 2-2.5cm into the rectum. It is then left in situ for about 2-3minutes
7. The nurse can hold it in place if the patient is not cooperative
8. Remove the thermometer and wipe from the stem to bulb
9. Read and shake the thermometer and record
10. Make patient comfortable
11. Discard tray and wash hands
12. Report any abnormality detected.
To take the rectal temperature of a baby
1. The baby should be wrapped in a blanket to immobilize the arms and should lie on his face
across the nurse’s knee.
2. The same procedure for cleaning, rinsing, lubricating and inserting as the adult.
3. On removal it is wiped with a swab, the reading noted and recorded
Rectal temperature is contraindicated in patients who has
1. Disease of the rectum
2. Diarrhea
3. Had rectal surgery
31
Pyrexia
Pyrexia also known as fever is an increase in the body temperature (above 37 0C) of an
individual beyond the normal range. It is a natural defensive mechanism of the body to fight
against infections.
Causes of pyrexia
Causes of pyrexia maybe infectious or non-infectious. Some of the common reasons of pyrexia
are
a. Infectious causes
- Complicated urinary tract infections
- Bone infections like osteomyelitis
- A bacterial lung infection called tuberculosis
- A bacterial infection of the cardiac tissue called endocarditis
- Viral infections like HIV
- Lower respiratory tract infections like bronchitis (inflammation of the air tubules that
carry blood in and out of the lungs)

b. Non- infectious causes

- Reactions to drugs
- Bowel or bladder related problems
- Malignant conditions like leukemia
- Neurological conditions like brain fever or hemorrhage

In fever all systems of the body are affected. It may vary with the nature of the disease
Respiratory system: shallow and rapid breathing
Circulatory system: increased pulse rate and palpitations
Nervous system: headache, restlessness, irritability, insomnia, convulsions
Musculo-skeletal system: malaise, fatigue, body pain, joint pain
Integumentary system: heavy sweating, hot flushes, shivering or rigor
Urinary system: diminished urinary output, burning micturition, colored urine
Alimentary system: dry mouth, coated tongue, loss of appetite, indigestion, vomiting, nausea,
constipation and diarrhea.

Types And Phases Of Fever

a. Intermittent fever

32
This fever has a fluctuating baseline between normal temperatures and fever levels over the
course of the day
b. Remittent fever
This type of fever may come and go, and temperature fluctuates but though it falls it never falls
all the way back to normal
c. Hectic or swinging fever
Either an intermittent or a remittent fever is considered hectic if the temperature range swings
widely throughout the day with a difference of at least 1.4 degree Celsius between the highest
and lowest temperatures
d. Continuous or constant fever
Also called a “sustained” fever, this a prolonged fever with little or no change in temperature
over the course of a day.
e. Relapsing fever
This is a type of intermittent fever that spikes up again after days or weeks of normal
temperatures. This type of fever is common with animal bites and diseases like malaria
f. Inverse fever
In this type, the highest range of temperature is recorded in the morning hours and the lowest in
the evening which is contrary to that found in the normal course of fever.
g. Crisis
This is where the temperature falls sharply to normal within 24hrs and there is improvement in
the pulse, respiration, and the general condition of the patient.
h. Lysis
This is when there is a gradual return to normal of a temperature of a patient taking 3 or 4 days
and there is sudden improvement in the pulse and respiration.
i. False/ pseudo- crisis
In this type of fever there is a decline of temperature but there is no improvement in the pulse,
respiration and general condition of the patient. In this type, the temperature rises again after a
short period of time.
j. Low pyrexia
In this the fever does not rise between 37.2- 37.8 degree Celsius
k. Moderate pyrexia
The body temperature remains between 37.8- 40.6 degree Celsius
33
 l. High pyrexia
The temperature remains between 39.4 - 40.6 degree Celsius
m. Hyperthermia
When the body temperature is raised to 40.6 or 105F
n. Hypothermia
Is when the temperature falls below 350 C

Rigor
Is a sudden severe attack of shivering in which the body temperature rises rapidly to a stage of
hyperpyrexia
Care in rigor
Rigor is characterized by three stages:
i. First stage or cold stage
The client shivers uncontrollably. The skin is cold, the face pale, the pulse feeble and rapid.
The temperature rises rapidly to 39.4 or above.
The management in this stage is cover the patient with blankets and apply warmth with hot
water bottle. Then give warm drinks and protect patient from falling.
ii. Second stage or hot stage
The skin feels hot and dry, and client feels very thirsty. The shivering stops and the client
maybe restless. The temperature may continue to rise.
In this stage remove all blankets and hot appliances. Cover the patient with thin blanket and
give cool drinks. Cold compress is applied to the head to relieve congestion and headache.
Temperature is carefully monitored and recorded every 10-15 minutes and also watch pulse and
respiration. If the temperature goes very high that is 40.6 cold sponging can be done and then
watch for early signs of sweating.
iii. Third stage or sweating stage
The client sweat profusely and temperature falls. The pulse improves and patient gradually
gains comfort. The client may go into a state of shock and collapse if not properly cared.
In this stage the clothes that are wet with sweat or cold applications are changed, give a quick
sponge and dry the patient. Cover the patient with light cotton blanket and change clothes.
Allow the client to sleep and also can serve sweet drinks to treat fatigue. Make patient

34
comfortable and continue to check temperature, pulse, and respiration without disturbing the
client every 15minutes.

Tepid Sponging
Is the process use to reduce temperature of a patient using tepid water (2-320C)
Requirements on trolley
o A bowl
o 2 jugs , one for hot and the other cold water
o Six flannels or face towels
o A temperature tray
o Long mackintosh and bath blankets
o A receiver for used water
o gloves

Procedure
1. Explain procedure to patient and provide privacy
2. Prepare trolley and send to bedside
3. Wash hands and dry
4. Take patient’s temperature, pulse and respiration and record
5. Arrange top bed clothes leaving top sheet
6. Protect the bottom and undress patient
7. Wash and dry patient’s face to refresh him/her
8. Leave a flannel or a towel which has been placed in the tepid water and leave on the
patient’s forehead
9. Place the other towels in the water
10. Place a wet towel in each axilla and groin, squeeze out excess water
11. Change the wet towel frequently to keep tepid
12. Sponge upper arms, trunk, lower limbs and back in strokes leaving small drops of water
on the skin
13. Change water as often as necessary
14. Leave patient for 15-20 minutes
15. Dress patient and recheck temperature and record
16. Thank and make patient comfortable in bed
17. Wash and dry hands and offer cold drinks if necessary
18. Document procedures and report findings.

Pulse

35
 It is the number of times the heartbeat in one minute. It is also known as the heart rate. It’s the
expansion of the arteries and is caused by an increase in blood pressure pushing against the
elastic walls of the arteries each time the heart beats. These expansions rise and fall in time
with the heart as it pumps the blood and then rests as it refills. The pulsations are felt at certain
points on the body where larger arteries run closer to the skin.
Sites at which pulse can be felt

 At the point in the wrist where the radial artery approaches the surface
 At the side of the lower jaw where the external maxillary(facial) artery crosses it
 At the temple above and to the outer side of the eye, where the temporal artery is near
the surface
 On the side of the neck from the carotid artery
 On the inner side of the biceps from the brachial artery
 In the groin from the femoral artery
 Behind the knee from the popliteal artery
 On the upper side of the foot

Characteristics of a pulse
Before assessing the pulse, the nurse should be familiar with the normal characteristics of a
pulse that is
a. Rate
b. Rhythm
c. Volume
d. Tension
Rate
Rate is the number of pulse beats in a minute. The normal rate in the resting is 60 to 100 per
minute.
A pulse rate over 100 beats per minute is referred to as tachycardia and
A pulse rate below 60 beats per minute in an adult is referred to as bradycardia.

The factors causing variations in pulse rate are

i. Age: the very young have a rapid pulse rate. The adults have a normal range of 70 to
80 beats per minute and the very old age have relatively slow pulse rate.
From birth to 2years- 100-150bpm
From 3years to 15years- 80-100bpm
Adult- 70-80bpm
Old age – 60-70bpm
ii. Sex: the female has a slightly more rapid pulse than the males.
36
iii. Exercise: increased muscular activity will increase the pulse rate
iv. Food: indigestion of food causes a slight increase in the pulse rate for several hours
v. Physique: the short person with small body build has a slightly more rapid pulse than
the tall heavy individual.
vi. Posture: the pulse rate is higher when the body is in the standing position than when in
sitting.
vii. Emotions: mental or emotional disturbances will increase pulse rate temporarily.
viii. Application of heat: application of heat can increase the pulse rate
ix. Disease condition: loss of blood, injury to the viscera, shock etc. increase the pulse
rate. Also, heart diseases and typhoid, infection also have a marked effect on the pulse.
x. Drugs: stimulant drugs e.g. Caffeine will raise the pulse rate and taking of sedative
drug can reduce the pulse rate
xi. Pain: a client in the agony of pain will have an increased pulse rate.

Rhythm
It refers to the regularity of beats. Normally the heart is spaced at equal intervals and are said to
be regular. When the interval varies between the beats it is said to be irregular. If an irregularity
is present the pulse should be counted for one full minute.
The abnormal rhythm in the pulse is seen in the following conditions:
a. Arrhythmias: it is a technical term that indicates any variation from normal rhythm.
b. Intermittent pulse: it is one in which the beats are missed at regular intervals. In
intermittent pulse, there is a difference between the apical and the radial pulse; it is also
known as pulse deficit.
c. Atrial fibrillation: rapid contractions of the atrium causing irregular contractions of the
ventricles in both rhythm and force
d. Extra systolic pulse: when the cardiac contraction occurs prematurely. i.e. before they are
normally due in the cardiac cycle, it is called extra systolic pulse.
e. Ventricular fibrillation: it is the rapid twitching of the ventricles. It is fatal
f. Dicrotic pulse: there is one heartbeat and two arterial pulsations giving sensation of a
double beat.
g. Sinus arrhythmia: it is a condition in which the pulse rate is rapid during inspiration and
slow during expiration
Volume

37
It refers to the fullness of the artery and is the force of the blood felt at each beat. Volume
depends upon the amount of blood in the arteries. If the arteries contain a normal volume of
blood, the pulse is said to be full or large in volume.
If the volume of blood is decreased by hemorrhage, the pulse will be weak, thereby small
feeble or flickering. When the pulse is large or full and also rapid in rate, it may be described as
bounding pulse.
The abnormal volume of pulse will be seen in the following:
1. Bounding valve: it signifies an increased stroke volume as seen in exercises, anxiety,
anemia, heart block and the water hammer pulse.

2. Water hammer pulse or Corrigan’s or collapsing pulse: it is a full volume pulse but
rapidly collapsing pulse occurring in aortic regurgitation or incompetence, where the
blood having been forced into the artery by the ventricular contraction, regurgitates back
into the ventricle owing to the non- closure of the aortic valve.

3. Pulsus alterans: the rhythm regular but the volume has an alternative strong and weak
character. This maybe noticed in the left ventricular failure, heart block

4. Bigeminal pulse: it is accompanied by an irregular rhythm in which every other beat

comes early. The second or premature beat feels weak due to inadequate filling of the
ventricles between two beats. It may be so weak that it fails to produce a palpable
peripheral pulse (pulse deficit). It is seen in myocardial infarction.

5. Weak / thread pulse: a small weak pulse that feels like a wire or thread on the palpation
of arteries and it signifies a decreased stroke volume and is seen in hemorrhagic shock or
loss of fluid from the body. E.g., diarrhea and vomiting

6. Paradoxical pulse: in this case the force or strength of the pulse wave varies feeling
weaker when the client takes in a breath. During inspiration less blood is returned to the
left side of the heart, reduces the stroke volume, and therefore decreases the strength of
the pulse. This may occur normally but if pronounced this may indicate cardiac damage.
Tension
Tension is the degree of compressibility and said to be high tension when the artery is difficult
to compress and low tension when it is easy to compress.
Frequency of taking pulse
The pulse is taken along with the body temperature twice a day for clients who are not
seriously ill. It may be taken frequently for clients who has surgeries, accidents or who are
38
 critically ill. Frequency depends upon the condition of the client and also according to the
doctor’s orders.
Steps for taking radial pulse
It is usually taken whiles checking temperature but can be taken separately.
1. Explain procedure to patient
2. Patient should be made comfortable and at rest
3. With your palm up, look at the area between your wrist bone and the tendon on the thumb
side of your wrist. Your radial pulse can be taken on either wrist.
4. Use the tip of the index and third fingers of your other hand to feel the pulse in your radial
artery between your wrist bone and the tendon on the thumb side of your wrist.
5. Apply just enough pressure so you can feel each beat. Do not push too hard or you will
obstruct the blood flow.
6. Note rhythm, rate, volume and state of arterial
7. Using the watch or pulsometer count for a full minute
8. Record on temperature, pulse and respiration chart
9. Make patient comfortable
10. Wash hands
11. Report any abnormalities detected

Respiration
The respiration rate is the number of breaths you take each minute. The rate is usually
measured when you are at rest. It simply involves counting the number of breaths for one
minute by counting how many times your chest rises. Respiration rates may increase with
exercise, fever, illness and with other medical conditions.
Respiration is the act of breathing in and breathing out and it includes inspiration and
expiration
Normal respiration rates for an adult person at rest range from 12 to 20 breaths per minute.
Normal respiration should be rhythmical, quiet, regular, and comfortable being too deep nor too
shallow.
The rate varies with age and sex
Newborn infants – 30 to 35breath per minute
Twelve months old- 25 to 30breath per minute
Two to five years- 20 to 25breath per minute
Adults – 14 to 18breath per minute
Old age – 10 to 24breath per minute

39
Factors which influence respiration:
o Sex: female has slightly rapid respiration than the male
o Exercise: exercise of any type increases the metabolic rate and stimulate respiration
o Rest and sleep: during rest and sleep metabolism is decreased so respiration rate is normal
or decreased
o Emotions: sudden stressful condition such as fear and anxiety influence the respiratory rate
o Changes in atmospheric pressure: in high altitudes the content of oxygen in the atmosphere
is very low. So, rate of respiration is in increased and the increased demand of oxygen is
fulfilled.
Abnormal respirations
a. Normal respiration: 16-20 beats per minute, regular rhythm, ratio of respiration and
pulse rate is 1:4
b. Hyperventilation or kussmaul’s breathing increased in depth and rate hyperpnoea-
increases in depth only.
c. Periodic respiration: alternating hyperpnoea, shallow respiration and apnea- some time
called Cheyne – strokes respiration frequently occur in severely ill.
d. Air trapping: present in obstructive pulmonary disease- air is trapped in the lungs,
respiration rate rise and breathing becomes shallow
e. Sighing respiration: deep and audible, is apparent by slow inspiration and rapid
expiration. This occurs in shock following hemorrhage.
f. Blot’s respiration: shallow breathing – interrupted by apnea found in CNS disorders
and sometimes in healthy persons
g. Stridor respiration: it is noisy shrill and vibrating respiration. It is due to obstruction in
the upper airway. It is commonly seen in laryngitis and foreign body in the respiratory
tract.
h. Wheezing: expiration is difficult and louder. It is due to partial obstruction of the
smaller bronchi and bronchioles. It seems in asthma and emphysema
i. Apnea: this is a temporary cessation of breathing due to excessive oxygen and lack of
carbon dioxide
j. Dyspnea: this is a forced, difficult, or labored breathing. It may be accompanied by pain
and cyanosis. It is seen in heart diseases, respiratory diseases, convulsions
k. Orthopnea: the patient can breathe only in upright position. Commonly found in
congestive cardiac failure
l. Cheyne- stroke respiration: this is respiration which gradually increases in rate and
volume until it reaches a climax. Then slowly pause occurs and breathing stops for 5 to
30 seconds and then cycle begins again. It is a periodic breathing usually found in the
patients who are near death.
m. Asphyxia: it is a state of suffocation when the lungs do not get a sufficient supply of
fresh air to the vital organs and they are deprived of oxygen
40
 n. Cyanosis: it is the blueness or discoloration of the skin and mucous membrane due to
lack of oxygen in the tissues
o. Rale: an abnormal rattling or bubbling sound caused by the mucus in the air passages in
seen in the bronchitis of pneumonia
p. Kussmaul’s respiration: respiration is abnormally deep but regular, rate is increased. It
is seen in diabetic ketoacidosis
q. Blot’s respiration: it is shallow breathing interrupted by irregular periods of apnea, seen
in central nervous system disorders.

How To Check Respiration

Requirements
o Watch with a second’s hand or pulsometer
o Pen
o Temperature chart

Steps
1. After checking pulse, with the hand still on patient’s wrist, observe patient’s respiration
with his awareness
2. Note rise and fall of patient’s chest during inspiration and expiration
3. The rise and fall count as a one cycle
4. Using the watch, count the respirations for a full minute to obtain the respiratory rate
5. Note depth of respirations. This can be assessed subjectively by observing degree of
chest wall movement while counting rate
6. Note rhythm of ventilator cycle. Normal breathing is regular and uninterrupted. Infants
breathe less regularly. Young child may breathe slowly and then suddenly breath
fastens
7. Record respiration on TPR chart
8. Make patient comfortable
9. Record any accompanying signs and symptoms of respiratory alternations in nurse’s
notes.

The Blood Pressure

Blood pressure is the force of blood against the walls of the arteries as the heart pumps blood
through the body. It is reported in millimeters of mercury(mmHg). This pressure changes in the
arteries when the heart is contracting compared to when it is resting and filling with blood. It is
typically expressed as a reflection of two numbers, systolic pressure, and diastolic pressure.
The systolic blood pressure is the maximum pressure on the arteries during systole (the phase
of the heartbeat when the ventricles contract). Systole causes the ejection of blood out of the
ventricles and into the aorta and pulmonary arteries.
41
The diastolic blood pressure is the resting pressure on the arteries during diastole (the phase
between each contraction of the heart when the ventricles are filling with blood).
Blood pressure measurements are obtained using a stethoscope and a sphygmomanometer also
called a blood pressure cuff.
The average blood pressure for a healthy adult is usually about 120/80mmHg. A systolic
pressure above 150 or below 90mmHg is regarded abnormal and a diastolic pressure above
90mmHg is considered abnormal.
Factors causing variation in blood pressure
a. Age
b. Sex
c. Body build
d. Race
e. Climate
f. Time of the day
g. Exercise
h. Pain
i. Emotion
j. Posture
k. Disease condition
l. Drugs
m. Hemorrhage
n. Increased intracranial pressure

Instrument Use In Measuring Blood Pressure

The standard instrument use to measure the blood pressure is called sphygmomanometer and
there are two types, they are mercury and aneroid.
A sphygmomanometer has three parts
1. A cuff that can be inflated with air
2. A pressure meter(manometer) for measuring air pressure in the cuff
3. A stethoscope for listening to the sound the blood makes as it flows through the
brachial artery.
The scale of the pressure meter ranges from 0-300 mmHg and has a rubber pump on it for
inflating the cuff and a button for letting the air out.
To measure blood pressure, the cuff is placed around the bare and stretched out upper arm and
inflated until no blood can flow through the brachial artery. Then the air is slowly let out of the
cuff. As soon the air pressure in the cuff falls below the systolic blood pressure in the brachial
artery, blood will start flowing through the arm once again. As sound will be heard with the
42
help of the stethoscope placed on the elbow and this first pounding sound is called systolic and
when the pounding sound stops is the diastolic and this can be read on the pressure meter.

How To Check Blood Pressure

Requirement

 Stethoscope
 Piece of paper
 Sphygmomanometer

Preparation of the patient

1. Explain the procedure to the patient to gain confidence and cooperation
2. Place the patient in a comfortable position either lying down with the arm resting on the
bed or sitting with the arm supported on the table.
3. Patient should rest at least 5-10minutes prior to taking blood pressure
Procedure
4. Wash hands and take equipment to bed side
5. Apply deflated cuff evenly with rubber bladder over the brachial artery, the lower edge
being “2” inch above the antecubital fossa
6. With the two tubes turning towards the palm, palpate the brachial artery with the
fingertips
7. Place the bell of the stethoscope on the brachial pulse and the stethoscope must hang
freely from the ears
8. Close the valve on the pump by turning the knob clockwise
9. Pump up air in the cuff until the pressure meter reads above 20mm above the point at
which the radial pulsation disappears
10. Open the valve slowly by turning the knob anti clockwise
11. Permit the air to escape slowly. Note the number on the manometer where the sound
begins
12. And this is called systolic pressure
13. Continue to release the pressure slowly
14. The sound become louder and clearer noting the point where the sound ceases, and this is
called diastolic pressure
15. Remove the cuff and assist patient to cover the arm that was exposed
16. Replace the apparatus back to its position
17. Wash hands and record the reading with date and time
18. Report any abnormalities for the necessary action to be taken.

Intake And Output Chart

43
Intake is the measurement of all those fluids entering the client’s body such as water, ice chips,
juice, milk, coffee, ice creams and fluid include parenteral, central line, feeding tube, artificial
irrigation, and blood transfusion.
Output is the measurement of all fluid level that leaves the clients body such as urine,
perspiration, exhalation, diarrhea, vomiting, drainage, bleeding, and wounds.
Intake and output chart is the measurement of a patient’s fluid intake by mouth, feeding tubes
or intravenous catheters. And output from kidneys, gastrointestinal tract, drainage tubes and
wounds. Accurate 24hours measurement and recording is an essential part of patient
assessment. Percent of water in the human body include
a. Fetus in the womb- 100%
b. Baby at birth – 80%
c. Normal adult- 70%
d. Elderly person- 50%

Indication Of Intake and Output Chart

 Fluid and electrolyte imbalance
 Kidney impairment patients
 In case of dialysis patients
 Clients with burns
 Recent surgical procedure
 Severe vomiting or diarrhea
 Taking diuretics or corticosteroids
 Congestive heart failure
 In case of dehydration
 Dark concentrated urine
 Excessive perspiration
 Any bleeding

Importance Of Measuring Fluid Intake and Output Chart

a. Measurement of intake and output can monitor progress of treatment or of a disorder
b. This provides information about retention or loss of sodium and ability of the kidneys to
concentrate or dilute urine in responses to fluid change
c. It helps the physician to give the right diagnosis and treatment by the accurate measurement
of intake and output

How To Record Intake and Output Chart

Requirement

44
 o Intake and output chart
o Paper and pen
o Calibrated drinking glass
o Bedside commode
o Male and female urinal
o Weighing scale
o Calibrated container to measure output
o Gloves

Procedure
1. Explain the purpose and procedure for measuring intake and output to the patient
2. Record the volume for all fluids consumed
3. Make sure that all IV fluids or tube feeding are being administered at the prescribed rate
4. Ensure that the nurse who adds additional IV fluid containers also record the volume
5. Keep track of fluid volumes used to irrigate drainage tubes or flush feeding tubes
6. Wear gloves
7. Measure and record the volume of voided urine, urine collected in catheter drainage bag,
liquid stool
8. Write all entries clearly
9. Wash hands
10. Check the volume remaining currently infusing IV fluid
11. Record the total amount of all fluid intake and output for every 24hours
12. Find out amount of fluid retained by subtracting output from intake
13. Inform the nurse in charge/ doctor immediately if amount put out is greater than the
amount taken or when there is abnormalities low output.

D. Maintenance Of Personal Hygiene

Bed bathing / bathroom bathing and grooming
Bed bathing
Bed bath means bathing a client who is confined to bed and who does not have the physical and
mental capability of self-bathing.
Indications

 Paralyzed patients
 Unconscious patients
 Plaster cast and traction patients
 Patients who have undergone surgery

45
 Purpose
1. To prevent bedsores
2. To stimulate circulation
3. To induce sleep
4. To clean the body off dirt and bacteria
5. To provide comfort to the client
6. To regulate body temperature
7. To establish an effective nurse-client relationship
8. To observe objective symptoms
9. To give the client a sense of wellbeing
10. To relieve fatigue

General instructions for giving bed bath

1. Maintain privacy of the client by means of screens, curtains, or drapes
2. Explain the procedure to win the confidence and the cooperation of the client
3. Wash hands before and after procedure
4. All articles used in bed bath should be clean
5. All needed equipment should be at hand and conveniently placed before beginning the
procedure so as to avoid leaving the client unnecessarily.
6. Only small area of the body should be exposed and bathed at a time.
7. Provide active and passive exercise whenever possible unless it is contraindicated.
8. Do not touch the body with hands. It is unpleasant to the clients
9. Cleaning is done from the cleanest area to the less clean area e.g. upper parts of the body
would be bathed before the lower parts
10. Avoid bathing a client immediately after a meal as it depletes the blood supply to the digestive
organs and interfere with the digestion.

Nurse’s Responsibilities In Giving Bed Bath

Preliminary assessment
1. Assess the client’s need for bathing
2. Check the physician’s orders to see the specific precautions if any regarding the
positioning and movement of the client
3. Assess the cardiorespiratory functioning, check temperature, pulse, respiration, and
blood pressure
4. Assess the client’s mental state to follow directions
5. Check the client’s preference for soap, powder etc
Requirements

46
  Bath basin (big size)
 Small size
 Soap with soap dish
 Sponge
 Bath towels
 Face towel
 Bath blanket or sheet
 Methylated spirit and powder
 Scissors or nail cutters
 Nail file
 Comb and oil
 Kidney tray and paper bag
 Jugs for cold and hot water
 Bucket
 Clean linen
 Laundry bag

Preparation Of The Client And Unit

1. Explain the sequence of the procedure to the client and explain how the client can assist
you if only conscious
2. Move the unnecessary items from the area
3. Place the items needed conveniently on the bedside table
4. Adjust the height of the bed to the comfortable working of the nurse
5. Check the room temperature and warm it if necessary
6. Close the windows if necessary and put off the fan to prevent draughts
7. Offer bedpan or urinal if necessary
8. Provide privacy
9. Keep the client flat if the condition permits. Remove extra pillows and back rest.
10. Remove the personal clothing and cover the client with bath blanket.

Procedure
1. Wash hands
2. Mix hot and cold water in the basin and check the temperature on the back of the hand. Fill
the basin half full.
3. Place the towel under the chin. Wash, rinse, and dry areas in the following sequence –
face, neck, farthest arm, near arm, chest, abdomen, back, farthest leg, near leg and pubic
area.

47
 4. Take a sponge or wash cloth wet it and apply soap on it and the clean the face, ears, and
neck. Put back the wash cloth back into the small bowl.
5. Take the other wash cloth, rinse it in water, squeeze it and clean the area where the soap
was applied, repeat the procedure till the area is cleaned.
6. Dry the face with face towel
7. Place the bath towel under the farthest arm, clean and dry arm as described for the face.
Pay attention to the axilla and support the arm of the joint.
8. Repeat the same for the other arm
9. Place the basin on the bath towel at the edge of the bed and the client place hands in the
basin. Rinse and dry thoroughly paying particular attention to the skin between the fingers
and the nails.
10. Place one corner of the bath towel over one shoulder and the opposite corner folded back
and placed on the other shoulder. Fold bath blanket down to the level of the umbilicus
11. With the left hand raised and the right hand mitted, clean the chest, replace the towel over
the chest between wash and remember to wash under the breast. Observe the chest and
breast for any abnormalities and note the respiration
12. While the towel remains on the chest of the patient, fold the towel down to the pubic area,
clean and dry the abdomen. Give special attention to the cleanliness of the umbilicus and
creased fold of the abdomen
13. Remove the towel and put back the bath blanket and cover patient completely
14. Change water. The waste water is discarded into the bucket
15. Turn the client to a prone position or side lying position with the face away from you and
make sure the client doesn’t fall down
16. Fold back the blanket from the shoulder to the thigh and tuck the edges and place the towel
over the bed, close to the back lengthwise
17. Wash, rinse and dry the back from the shoulders to the buttocks with brisk circular
movements. After drying the back give, a thorough back rub with methylated spirit and
powder. Pay attention to the pressure points.
18. Put on the upper garments and cover him with the bath blanket
19. Change water
20. Expose the farthest leg. Place the bag towel lengthwise under the leg. Flex the knee so that
the sole of the foot is supporting on the mattress. Place the basin on the towel and keep the
foot in the basin. Wash and rinse the thigh and leg with the wash clothes. Clean the foot
under the water paying attention to the toes and nails.
21. Remove the basin and dry the entire leg and repeat the procedure on the near leg
22. Wash the pubic area. It can be done by the client if he is able. If he is not able to it for
himself the nurse does for him making sure that the entire area is washed thoroughly and
dried.

Care of the client after bed bathing

48
 1. Replace the client’s personal clothing
2. Straighten the bed linen
3. Remove the bath blanket and put it for washing
4. Change the bed linen if needed
5. Offer a hot drink if permitted
6. Cut short the fingernails and toenails
7. Comb the hair and arrange the hair
8. Position the client for comfort and proper alignment
9. Disinfect the articles used and send soiled linens to the laundry

Bathroom Bathing and Grooming

A person who can to the bathroom should be encouraged to have his usual bath with assistance
if necessary.
There are reasons for bathing patients in the bathroom
a. As a prescribed treatments for patients who have surgical wounds which are healing by
granulation
b. Cleansing bath for ambulant patient

Tips On Assisted Bathing In The Bathroom

 Keep the bathroom warm to prevent the person becoming chilled

 Always check with the person if he needs to go the toilet before bathing
 Assess the level of assistance the person required. Some people may only need help in
undressing, washing the back and feet (these areas may be too difficult for them to reach
and clean), drying and dressing.
 If the person is using the bathtub, run the cold water into the bathtub first to prevent the
bottom from becoming hot enough to burn. This will also help to reduce the amount of
steam in the bathroom.
 Test the temperature of water with your elbow. The water should be comfortably warm.
Check with the person if the water temperature is comfortable to him.
 If the person is using a shower, provide him with a shower chair if he is less mobile. This
would enhance safety and also prevent him from becoming exhausted.
 For one who can help himself, make sure that the toiletries and clean clothes are in the
bathroom within easy reach.
 Advice patient not to lock door from inside in case of emergency, for safety reason. You
may leave him alone in the bathroom but stay within a call so that if he feels unwell you
can help.
Requirements needed

49
 o Bath towel and face towel
o Washing flannels
o Soap, nail-brush, scissors
o Night gown or pyjamas
o Slippers
o Bath thermometer

Procedure
In this one if the nurse is with the patient in the bathroom
1. A screen is placed round the bath separating it from the door
2. Windows should be closed if the weather is +cool, and a chair put in position
3. The patient is asked by the nurse to the face at the sink and use face towel to clean.
4. The nurse prepares the bath whiles the patient dries the face. Cold water is run in first
before hot water and they are mixed together at temperature of 38 0C and taken by a bath
thermometer
5. The patient can be undressing while the bath is being prepared
6. The patient is then assisted into the bath and fit to do so will usually wash himself but if
not, the nurse does it. Care should be taken when cleaning the feet, umbilicus, and all skin
folds.
7. After washing has been completed the patient is assisted out of the bath, dried, and dressed
in dressing gown and slippers. This is the convenient
8. time to take the weight of the patient.
9. The patient is then assisted back into bed and the nurse goes back and clean the bathroom,
open the window, and bring back the patient dirty clothes and toiletries.
10. It should be noted that whiles the patient is in the bathroom the nurse should look for any
abnormalities like pressure sores, swollen areas, abrasion of the skin, scars, pediculosis,
rash and if any is found should be reported to the nurse in charge and the necessary action
taken.

Care Of Pressure Areas

Pressure areas are those parts of the body particularly over bony prominences which may be
subject to pressure and friction resulting in blood supply to these parts.
Areas most likely to be affected are:
1. The elbows
2. The lateral aspects of the hip joints
3. The heels
4. The medial, anterior, and lateral aspects of the knees
5. The medial and lateral aspects of the ankles
6. The back of the head, particularly in elderly men and babies
50
 7. The shoulder blades
8. The thoracic and sacral regions of the vertebral column especially in thin patients

Predisposing causes
Pressure sores happens if you cannot move around or stay in one position for a longer time. We
normally move around about constantly even in our sleep. This stops pressure sores from
developing.
If you are ill, bedridden or in a wheel chair you are at risk of getting pressure sores
Several things can increase your risk of pressure sores. These include:
1. Weight loss- having less padding over bony areas
2. Friction or rubbing of the skin for example against sheets
3. Poor diet
4. Lack of fluid(dehydration)
5. Moist skin for example due to sweating or incontinence
6. Other medical conditions such as diabetes
7. Having a previous pressure ulcer
8. Being unable to move around easily due to old age or illness (unconscious or paralyzed
patients)
9. Sliding down in a bed or chair – pressure on the skin cuts off blood supply because the skin
is being pulled in different directions called shearing.
10. People who are very obese or edematous
11. Convulsive or agitated patients
12. Patients with poor circulation like heart failures and respiratory diseases.

The actual causes of pressure sores are friction, moisture, and pressure
 Pressure occurs due to:
1. When client is allowed to stay or lie in one position for a longer time
2. Badly or tightly applied bandages or splint
3. One limb pressing on the other in paralyzed patient
4. when accessories like sandbags which is heavy press on the limbs for a longer time
5. when emaciated patient is left on the unpadded bed pan for a longer time
 when due to moisture
When the skin comes into contact with moisture for a long-time maceration of the skin
occurs. Moisture can come as a result of
1. incontinence of faeces and urine
2. dropping of water on bed clothes
3. accumulation of sweat in the skin folds of skin example in the gluteal fold, under the
breast of obese women

51
 4. not paying attention to toilets when defecating and urinating

 when due to friction

Rough or hard surfaces with the skin cause friction and subsequent tissue damage.
Wrinkles and crumbs in the bed sheets and patches of bed linen, hard surfaces of plaster,
cast can cause friction. Also, the use of cracked bedpans and pulling of bed sheet under the
patient frequently.

Signs and symptoms

1. Skin that feels cooler or warmer to touch than other areas.
2. Skin loss exposing deeper layers of skin
3. skin swelling or local edema
4. appearance of reddish-purple area or discoloration of the skin
5. pus like drainage from an open area of skin
6. pain or tenderness around the area

Prevention of pressure sores

Prevention of pressures sores are grouped into 3
1. relieving direct pressure
2. skin care
3. general tips

Relieving direct pressure

 asking patient to stand up if he can
 use special pressure relieving mattresses and cushions
 change position at least every 2 hours
 tell patient not to drag heels or elbows when moving in bed or chair
 ask patient to change position and keep moving as much as possible
Skin care
 keep patient skin clean and dry
 avoid using talcum powder as it dries the skin natural oils
 moisturize patient skin thoroughly after washing
 avoid scented soaps as they can be more drying
 attend to pressure points as often as possible to stimulate circulation
 teach patient and family the hygienic care of the skin
General tips
 make sure the bed sheets of patient are smooth and not wrinkled
 sheets should be cotton or silk like fabric

52
  patient should eat a well-balanced diet and enough fluid (at least 2litres of water a day)
 call for assistance in lifting patient well before serving bedpans
 use bed cradles to lift the weight of linens from patients
 change bed linen as soon as they are wet
 Use adequate amount of cotton under splints and plaster cast to prevent friction.

Treatments Of Pressure Sores

Even though it can be prevented, some patients may develop it due to condition. The
difficulty in treatment may depend on the position or location of the sore.
Pressure sores can be treated in many ways depending on the stage. Once the stage and
severity of wound is determined:

 It must be cleaned with saline solution and after the wound is cleaned, it needs to be
kept moist and covered with an appropriate bandage.
 Sometimes debridement is needed. This is the process of ridding the wound of dead
tissues. It is an important part of the healing process. It changes the wound from a long
lasting (chronic) one to a short term (acute) wound.
 Application of waterproof ointment example zinc oxide on the surface of the wound
will prevent infection of the underlying tissues. It also helps in incontinent patient.
 Using honey or granulated sugar to fill the cavity of the wound to aid healing.
 Report to the ward in charge and the doctor the early symptoms of pressure sores so
that measures will be put in place to prevent further damage.

Requirements for the treatment of pressure sores

The same as for bed bathing
Steps
1. Explain procedure to the patient
2. Set trolley and send to bed side alongside prepared lukewarm water
3. Provide privacy with screen
4. Remove patient’s clothes and cover with a sheet
5. Protect bed with mackintosh and a draw towel
6. Roll patient onto the side with the head turn to one side
7. Examine and note any abnormality
8. Clean all pressure areas (back of hand, scapula, sacrum, hips, knees, ankles, heels, and toes)
with soap and water in a soft towel with gloved hand
9. Kneed all pressure areas with the tip of fingers, one area at a time
10. Rinse and dry skin with a soft dry towel ensuring that there is no moisture
11. Apply moisturizing cream or alcohol-free barrier creams
12. Dress patient and make comfortable in bed (changing of sheets)
53
13. Change position of patient for some time
14. Thank patient and discard trolley
15. Wash and dry hands
16. Document procedure and findings
17. Inform in charge about any abnormality (discoloration blister or broken skin)

Care Of Hair
Care of the hair is part of personal hygiene. It is another way of helping the patient feel good
about her and maintain a good mental attitude. A patient’s hair should be combed daily. In
addition, it helps to enhance morale, stimulate circulation of the scalp, and prevent tangled,
matted hair.
Types Of Hair Care
There are three types of hair care
1. Daily care by brushing and combing
2. Head bath(shampooing) in order to maintain its cleanliness
3. Treatment of hair for lice infestation

Factors that promote hair growth

a. A well-balanced diet
b. Light and fresh air
c. Daily practices (hair wash and combing)
d. Hair brushing and massaging
e. General health of a person
Factors affecting hair
a. Aging and immobility
b. Insect bite and infestation
c. Hormonal changes
d. Physical and emotional stress
e. Poor health practices
f. Effects of drugs
g. Physical weakness or disease condition
h. Altered level of consciousness
Benefits for hair care
1. To promote growth of hair
2. To have a neat and tidy appearance
3. To prevent itching and infection

54
4. To stimulate circulation
5. To prevent tangles
6. To prevent loss of hair
7. To keep hair clean and healthy
8. To promote comfort
9. To have a sense of well being

Common Hair Scalp Problems

a. Dandruff- sealing of scalp accompanied by itching
b. Pediculosis- lice infestation
c. Alopecia- hair loss
d. Tangled and matted hair
e. Dryness
f. Flakes
g. Irritation
h. Scabies and ringworm

Preliminary assessment
Check for:
1. Doctors order for specific precautions
2. General condition and self-care ability
3. Mental status to follow directions
4. Condition of the scalp and hair
5. Articles available in the unit

Hair Wash Or Bed Shampoo

Hair wash or bed shampoo is a special care of the hair maybe required for patients who are in
bed for a prolonged period of time.
General instructions
1. Avoid hair wash for patients who have just taken meals at least for an hour.
2. Avoid expose and chilling by keeping the patient covered with top clothes
3. Do not let the patient exert and try to avoid exertion to the patient as far as possible
4. If the patient is very sick note the pulse before and after the hair wash
Requirements
o A tray containing bath towels-2

55
 o Face towel
o Long mackintosh-2
o Hair comb
o Kidney tray
o Liquid soap or shampoo
o Cotton wool balls and pomade
o Bucket
o Mug to collect water for rinsing
o Jugs-2(hot and cold water)
o Bowl
o Clean linen
o Diluted antiseptic solution in a bowl
o Hair dryer if necessary

Steps
1. Explain procedure to patient
2. Arrange the articles at the bedside
3. Provide privacy and close windows
4. Change patient’s bed clothes to bathing clothes and cover with sheet
5. Position the patient flat comfortably to the edge of the bed if condition permits or supine
position
6. Remove the extra pillows and back rest
7. Place one pillow under shoulder so that the patient head is slightly tilted
8. Make an improvised trough (Kelly’s pad) and place it under the hand to facilitate the
drainage of water into receptacle.
9. Place the bucket on the low stool close to the side of the bed. The distal end of the
mackintosh (trough) is received into it.
10. Plug the ear with cotton wool swabs
11. Loose and comb hair and fold one bath towel around the neck
12. Mix hot and cold water and test the temperature
13. Give the patient a washcloth for his eyes and face
14. Check the provision for water drainage before pouring any water
15. Wet hair and apply shampoo. Lather and rinse
16. Reapply the shampoo starting at the headline and working towards the back of the head.
Also massage all areas of the scalp with the fingertips
17. Add water as needed to keep a generous latter soap
18. Rinse the hair repeatedly until hair is clean
19. Squeeze water from hair
20. Dry the hair by gently rubbing it with a clean towel
21. Remove the equipment and wipe up any water spilled on the floor
22. Assist the patient to comb and brush the hair with a clean comb and brush
56
23. Remove cotton wool swabs from the ears and discard
24. Place patient in a comfortable position, dry hair, comb, apply pomade and arrange hair
when completely dry
25. Change linen if wet
26. Thank patient and disinfect items
27. Wash hands thoroughly and document findings.

Hair Combing
The hair can be combed and washed in the morning so that the patient can feel refreshed and
appear well groomed before starting daily activities.
General instructions
1. Hair needs to be brushed daily in order to be healthy
2. Long hair should be combed at least once a day to prevent it from matting
3. Teeth of the comb should be dull to prevent scratching of the scalp
Requirements

 Clean comb with fine teeth

 Two clean towels
 Mackintosh
 Kidney tray with antiseptic to destroy the lice and disinfect the comb
 Kidney dish
 Oil or pomade
 Paper bag
 Mask, apron and gloves

Procedure
1. Explain procedure to patient
2. Wash hands and take required articles to bedside
3. If possible, ask patient to sit on a stool or chair otherwise side lying or fowler’s position
4. Provide privacy
5. Place the mackintosh and towel under the patient head
6. Wash hands wear mask and gloves
7. Separate the hair into small strands. To prevent pulling hold strands above the part being
combed so that there will be no pain to the patient.
8. Comb and tangle out from the end first and then go up gradually. Use oil to remove tangles
9. After combing the hair thoroughly use ribbon to tie the hair making sure that the feels
comfortable to lie down with it.
10. Discard the loose hair in the paper bag
11. Place the patient comfortable in bed and tidy
57
12. Replace the articles to the utility room
13. Wash hands, thank patient and document findings.

Problems Of Neglected Hair Care

Neglected hair care cause sticky and heavy and acquires a sour unpleasant odor which may be
quite distressing to the patient.
One common hair problem is pediculosis which is associated with poor hygiene, crowd living
condition and exposure to other individuals.
Pediculosis is the state of being infested with lice singular- louse). The lice are blood suckers’
animals and can cause anaemia. Their names vary according to their location
1. Pediculus capitis which infests the head/hair
2. Pediculus corporis which infests the body
3. Pediculus pubis which infests the axillary and pubic hair, eyebrows, eyelashes
Dangers of pediculosis
a. They can anemia
b. They spread disease like typhoid fever, trench fever
c. They can cause severe itching and scratching of the scalp which can lead to abscess
formation.
Prevention
1. Combing the hair daily
2. Washing of the frequently
3. Keeping the skin and clothes clean
4. Thorough examination of the hair scalp, body and linen frequently.

Treatments
In the case of lice on the body and clothes, heat is applied to the clothes before wearing (seams
of garment) and application of benzene hexachloride.
With the one on the pubic and axillary hair can be shaved and parasiticide applied. Also, those
present at the eyebrows and lashes can be removed manually with a dissecting forceps.
With the hair, it can be treated with D.D.T 5% (add talcum powder dilute), benzene
hexachloride and equal portion of kerosene and coconut oil.
The parasiticide is applied to the hair and covered overnight, the hair is washed, and the patient
bathed. The linen is washed, and the process is repeated in a week’s time.

58
Treatment Of Pediculosis Hair
Requirements
o Mackintosh
o Gown or mask
o Bath clothes
o Paper bag
o Hair comb
o Cotton wool swabs or gauze in a gallipot
o Vaseline
o Kidney dish with disinfectant
o Two bath towels
o Towel folded diagonally with safety pins
o Bucket with antiseptic lotion
o Apron and gloves

Procedure
Procedure is the same as combing hair in bed up to where the patient hair is parted into parts.
1. Apply the parasiticides to the hair, roll up the hair to the top if long and cover with a cap
and secure with pins.
2. The procedure is done in the evening and left-over night
3. Remove mackintosh and towel and put in to bucket containing antiseptic
4. Tidy up the bed and make patient comfortable
5. Remove gown, mask and cap and place them in antiseptic
6. Take articles to the utility room and disinfect
7. Thank the patient, wash hands and record procedure
8. Explain to patient for the need for the repetition of procedure in a week’s time
9. Wash hair in the morning and comb.

Mouth Care
Mouth care or oral hygiene is the provision of appropriate care to ensure that the tissues and
structure of the mouth are in a healthy state.
Mouth care involves oral assessment appropriate mouth care, evaluation of care and
documentation of care.
Mouth care is the fundamental aspect of nursing.
Effective mouth care prevents both potential oral and systematic infection as well as distress
and discomfort to the patient (Xavier, 2000).
59
Purpose

 To maintain the healthy state of mouth, gums, teeth, and lips

 To stimulate appetite
 To provide a sense of well-being
 To remove dental plaque
 To prevent sores and infection of the oral tissues
 To remove food particles from and between the teeth
 To relieve discomfort resulting from halitosis and taste
 To prevent the mucous membrane from becoming dry
 To prevent sordes which results in ulceration
 To clean and moisten the membranes of the mouth and lips

Indications
1. Post-operative patients
2. Unconscious patients
3. Patients breathing through the mouth
4. Paralyzed patients
5. Patients with infections and disease of mouth
6. Seriously ill patient
7. Patient with fever
8. Malnourished and dehydrated patients
Complications of neglected mouth
A. Halitosis
B. Adenitis
C. Stomatitis
D. Glossitis
E. Sordes and crust
F. Root abscess
G. Anorexia
H. Parotitis

Mouth Care for A Conscious Patient

Requirements
o Bowl for dentures
o Tooth paste and brush
o A sputum mug or receiver for used water
o Mackintosh and towel
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 o Vaseline
o Towel for protection
o Gloves
o Cup of water/ mouth wash

Procedure
1. Explain procedure to patient
2. Arrange requirement for patient
3. Assist patient into a suitable and comfortable position
4. Place towel under chin for protection
5. Give brush with paste/chewing sponge/stick to him
6. Encourage patient to brush the teeth
7. Cleans the mouth thoroughly but gently inside the cheeks, both sides of gums, tongue and
palate
8. Give water or mouth wash and void content into a receiver
9. Apply Vaseline to the lips if necessary
10. Make patient comfortable in bed
11. Clears away used items
12. Washes and dries hands, record procedure and reports any abnormalities

Mouth Care For Seriously Ill/Unconscious Patient

Requirements
A tray containing the following
o Two gallipots (for mouth cleaning lotion and cotton wool or gauze)
o Bottle containing the mouth cleaning lotion e.g. normal saline, sodium bicarbonate
o Artery, sponge, or dressing forceps
o Dissecting forceps
o Bowl for dentures
o Vaseline or glycerine
o Receiver for used swabs
o Orange sticks(toothpick)
o Mouth gag
o Padded spatula or tongue depressor
o Gloves
o Mackintosh and towel

61
Procedure
1. Explain procedure to patient if conscious if not to the relatives
2. Provide privacy
3. Prepare a tray and take it to the bedside of patient
4. Put patient in a suitable position
5. Protect patient gown and bed linen with mackintosh and towel
6. Pour lotion into gallipot washes and dry hands
7. Clean the lips and outer of teeth and opens mouth with padded spatula
8. Keep the mouth open with the mouth gag if unconscious and inspect the mouth for
abnormalities
9. Remove dentures if any into the bowl
10. Take swab with forceps dip into cleansing lotion and squeeze out excess
11. Clean mouth thoroughly but gently i.e. from inside the cheeks both sides of the gum,
tongue and palate changing swabs frequently
12. Control movement of the tongue with the spatula
13. Use toothpick to clean in between of teeth
14. Clean mouth with water or any mouth wash
15. Clean lips and apply Vaseline
16. Clean dentures if available and replace back
17. Thank patient
18. Make patient comfortable in bed and remove screen
19. Discard tray, decontaminate, washes and sterilize instruments
20. Wash hands and document procedures and findings

Serving Of Meals and Feeding of Helpless Patients

A variety of menus is needed in hospitals to cover the requirements of many different types of
patients. Guidelines are aimed at maintaining a healthy weight and helping to prevent long term
diseases like hypertension. In view of this, diet scales are drawn up in hospitals to help patient
on admission and they are light diet, full or normal diet, convalescent diet, fluid diet and special
diet.
 A normal diet or full diet consist of all types of food in their correct proportion
 A light diet consists of very easily digested food such as chicken minced stew, milk
 A convalescent diet also consists of all types of foods minus fried foods
 Special diets also depend on the individual patient, religious background, and tribe
 Fluid diet should nourish, stimulating

Feeding The Helpless Patient

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Is assisting a dependent patient to take food and fluids
Purpose
a. To assist the patient to eat meal
b. To promote health
c. To prevent dehydration
d. To improve appetite
e. To meet the nutritional need of patient
General instructions
1. Small and frequent meals are preferable for a sick person
2. Meals should be served in clean and covered vessel
3. The diet is prescribed by a doctor or dietician and served by a nurse
4. Food should be served at correct time in a pleasant manner and in a pleasant atmosphere
5. Maintain a chart for intake of food and fluids for seriously ill patients
6. The patient should be free from pain and other discomfort during mealtime
7. Food should not be too hot or too cold
8. Give enough time for patient to enjoy meal
9. Be careful not to spill food. Wipe the patient mouth and chin whenever necessary
10. Wash patient hands and make him brush his teeth after meals
Requirements
A tray containing
i. A glass of water to give at the end of the meal
ii. Napkin to wipe the face in between
iii. Mackintosh and towel
iv. Feeding cup and spoon
v. The required amount of feed in a mug at the right temperature
vi. Kidney tray

Procedure
1. Explain procedure to patient
2. Provide privacy
3. Create a pleasant environment for the patient by well-ventilated, free from noise and
unpleasant sight
4. Send visitors away tactfully
5. Give bed pan or urinal to patient if required before meals
6. Wash hands and send tray to the bedside
7. If patient can sit help him and have flowers position on cardiac table
8. Wash patient hands if he can
63
9. Place towel over the chest and under the chin to protect clothing and the bed linen
10. Feed the patient using spoon
11. Offer water as required
12. Feed till patient is full but should be done in bits
13. After meals rinse the mouth and wash hands if patient fed himself and wipe.
14. Remove towel around the neck and make patient comfortable in bed
15. Thank patient and discard tray
16. Wash hands and document procedure making sure that is entered into the intake and output
chart and nurses’ notes.

Nasogastric Tube Feeding

Is given food or fluids through tube which is inserted through patient’s nose into the stomach
when patient is unable to take food orally.
It is the administration of fluid food by means of tube passed into the stomach which is called
the gastric gavage
Purpose
a. To provide adequate nutrition
b. When condition of the mouth or esophagus makes swallowing difficult
c. To introduce food into the stomach when the patient is not able to take food in the usual
manner
d. To give large amounts of fluids for therapeutic purpose
e. To assess tolerance of feeds in postoperative patients.

Indications
1. Unconscious patient or semiconscious
2. After certain surgeries of the mouth and throat
3. Patients unable to swallow
4. Premature babies
5. When is unable to retain the food e.g. anorexia nervosa

General instructions
1. Give mouthwash frequently to avoid complications of a neglected mouth
2. Maintain intake and output chart accurately
3. Measure and drain the feed(fluid) to avoid blockage in the tube
4. Avoid introducing air into the stomach during each feed. Pinch the tube before the fluid run
into the stomach completely
64
 5. Feeding maybe given at intervals of 2,3 or 4 hours and the amount is not exceeding 150 to
300mls per feed
6. Observe for complications such as nausea, vomiting, stomach distension, diarrhea,
aspiration pneumonia, asphyxia, fever and water and electrolyte in balance
Requirements
A tray containing :
o Mackintosh and towel
o 20 cc syringe
o Stethoscope
o Bowl with water
o Adhesive with scissors
o Feeds and water
o Measuring glass

Procedure
1. Explain procedure to patient if conscious
2. Provide adequate privacy
3. Set prepared tray to the bed side
4. Position patient in a sitting or semi- fowlers position
5. Place mackintosh and towel around the neck
6. Wash hands thoroughly
7. Make sure the tube is in the stomach by testing before giving the feeds
8. Remove spigot, pinch the tube to prevent air entry. Remove plunger from syringe and
connect to tube
9. Keep the syringe 12inches above the patient’s head. Start feed with small, measured
amount of water and allow feed to follow slowly and steadily through tube in such a way that
air does not enter tube
10. Do not force fluid, allow to flow by gravity
11. At the end of feed flush tube by pouring small, measured amount of water
12. Remove syringe and replace spigot
13. Remove mackintosh and towel
14. Thank patient and make comfortable in bed
15. Wash hands and discard tray
16. Record procedure in nurse’s notes and intake and output chart

Serving Of Bedpans and Urinals

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Bedpan use today is not that different from use in the 18 th century. Bedpans are a way of
addressing elimination concerns when the traditional toilet is not an option due to high risk of
injury or debilitating illness in sick, bed confined individuals.
There are 2 types of bedpans: regular or fracture. The regular bedpan is larger than its fracture
counterpart.
The fracture pan is used for patients with specific fracture like hip fractures, hip replacement or
lower extremity fractures.

Indications
Medical necessity may warrant the use of a bedpan for example as with immobile patients with
the following concerns:

 Fractures: hip, lower extremity

 Debilitating illness or profound fatigue
 Surgical considerations
 High fall risk and increased injury potential
 Obstetrical and gynecological

Points to note:
a. Placing a patient on a bedpan requires a special technique and is reserved for those that are
on bed rest per a health care provider order or discretion.
b. A patient can assist with care by raising their hips is approached differently than a patient
that cannot lift their hips due to surgical considerations, fractures or other contraindications.
c. If they can assist with raising their hips, then raise the head of the bed at least 30 degrees.
d. Positioning in the semi-fowlers position allows for anatomical support and facilitates ease
of defecation and urination by assuming a natural position for this bodily function.
e. The bedpan is introduced from the right-hand side of the bed unless for some reason this is
not suitable
f. Any appliances are first removed e.g. bed cradle
g. The bedpan should be covered with a special bedpan cover and is usually made of paper
and used once.
h. The pillows should be placed in a comfortable position and give support where required.
Requirements on trolley
Top shelf
o A bowl
o A jug of water
o Soap in a soap dish
o A towel
66
o Toilet roll
o Disposable gloves
o Draw sheet and mackintosh (this is brought along so that in a situation where the draw
sheet in place gets soiled it can be replaced)
Bottom shelf
a. A warm bedpan
b. Receptacle for used toilet roll

Procedure
1. Explain procedure to patient
2. Provide privacy
3. Bring things needed to the bed side
4. Stand at the right side of the bed with assistant on the other side
5. The nurses stand at either side of the bed, the nurse at the left side placing her hand at the
sacrum and thighs and the one at the right side placing her left hand under the sacrum; they
lift together, and the bedpan is slipped into position from the right side
6. Lift patient again with assistant to remove the bedpan after use, cover the bedpan
immediately
7. Cleans patient
8. Arrange bed clothes and leave patient comfortable in bed
9. Allow patient to wash hands with soap and water and dry hands
10. Take bedpan to the sluice room and inspect content before emptying it
11. Measure urine if any and when necessary and records
12. Empties bedpan and decontaminates, washes, and sterilizes
13. Wash and dry hands and remove screen
14. Documents procedure and reports any abnormalities

Giving Of Urinal To A Helpless Patient

Is the same as the bedpan but with these men are given urinal to urinate and women are given
bedpan for both. The urinal must be covered whiles being carried away. The urine is also
inspected at the sluice end before it is emptied, and abnormalities recorded.

The Use Of Sanitary Chair And Commodes

Bedside commode is an adult potty chair and is made up of a frame equipped with a toilet seat
and a removable bucket. As the name implies bedside commodes are commonly placed at the

67
bedside to be used as a portable toilet by patients who have difficulty getting to the bathroom
on their own or with enough time.
Sanitary chairs are used in place of bedpans. The chair is taken to the bed side and the patient is
dressed in a gown and slippers. The patient is then assisted out of bed into the chair and taken
to the lavatory. The chair is designed in such a way that the patient is able to use the toilet
whiles on the chair and after using it the patient is wheeled back into bed comfortably.

Collection Of Specimens
Specimen collection is the process of obtaining tissue or fluids for laboratory analysis. It is
often a first step in determining diagnosis and treatment. Those which are of concern are urine,
stool, sputum, and vomitus.
Concepts of specimen collection
a. Collect the specimen at the best time possible e.g. early morning, midstream
b. Collect specimens before the administration of microbial agents whenever possible
c. Collect the specimen from the actual site of infection without contaminating adjacent
tissues and secretions
d. Label the specimen properly with the following information: name, the ward and bed
number, date and time of collection, type of specimen and examination required. Also fill
out test request form completely.
e. Collect ample amount of sample by using appropriate collection device such sterile and
leak proof specimen containers
f. Close containers firmly after collection
g. Lessen transport time and maintain an appropriate environment between collection of
specimens and delivery to the laboratory.

Nurse’s Role In Specimen Collection

1. Patient interaction
2. Suitable selection of supplies
3. Appropriate and proper collection
4. Precise sample identification
5. Up-to-date transfer to the laboratory

Urine specimen and culture

A urinalysis also known as routine and microscopic is the physical, chemical and microscopic
examination of urine. It involves a number of tests to detect and measure various compounds

68
that pass through the urine. The color, density and odour of urine can reveal much about the
state of health of an individual.
Urine is assessed first for its physical appearance
Color
Normal urine color ranges from pale yellow to deep amber in color depending on the
concentration of the urine. The amount and kinds of waste in the urine make it lighter or darker.
Pigments and other compounds in certain foods and medications may change the color of urine
into dark brown.
Blood in the urine colors it; if the amount of blood in the urine is great, the urine will be red or
smoky.
Dark brown or tea coloured urine indicates a sign of liver disorders showing the presence of
bile especially accompanying pale stool and jaundice.
Cloudy or murky urine indicates that blood, pus or excess mucus are present and a sign of
urinary tract infections and kidney stones.
Odor
Urine normally doesn’t have a very strong smell. When urine stands, decomposition from
bacterial activity gives it an ammonia –like odor.
When urine also take on a foul-smelling odor it can indicate urinary tract infection.
Hazy urine which smells fishy usually shows a sign of bladder infection.

Types Of Urine Specimen

1. Midstream specimen of urine
Also known as “clean catch” urine collection is the most common method of obtaining urine
specimens. This method of method allows a specimen which is not contaminated from external
sources to be obtained without catherization.
It is used to prevent germs from the penis or vagina from getting into a urine sample.
Equipment

 Sterile specimen cup or pot

 Gauze swab, soap and water
 Paper towels
 Toilet, urinal or bedpan
 Apron and gloves

69
Procedure
1. Explain the procedure to gain cooperation from the patient
2. Ensure privacy
For female patient
1. Wash hands with soap and water
2. Instruct the patient to clean perineal area with antiseptic solution using gauze swabs only
once, using downwards strokes and then clean with paper towel.
3. Instruct the patient to void a small amount of urine into the toilet to rinse out the urethra,
void the midstream urine into the specimen cup and the last of the stream into the toilet.
For males
1. Wash hands with soap and water
2. Instruct the patient to completely retract foreskin and cleanse penis with antiseptic solution
using gauze swabs once and dry.
3. Ask the patient to start urinating into the urinal/toilet then stop, pass the middle part of the
stream into the specimen cup and the finish the rest into the urinal/toilet
Post procedure
1. Wash hands and instruct patient to do as well
2. Make patient comfortable
3. Discard all items
4. Make sure the specimen cup is tightly closed
5. Label the specimen container with patient identifying information and send to the
laboratory immediately with the request form.
6. Wash hands again and note the time and date specimen was collected into the nurse’s note.
Record any difficulties the patient had or if the urine had an abnormal appearance.
24 -hour urine collection
For many urine chemistry procedures, the specimen of choice is 24-hour urine. A 24-hour urine
collection is performed by collection is performed by collecting a person’s urine in a special
container over a 24- hour period. It always begins with an empty bladder so that the urine
collected is not left over from previous hours. The specimen collected shows the total amounts
of wastes the kidneys are eliminating. It is also used to assess kidney function and detects
diseases.
Equipment

 large clean bottle with a cap or stopper

 measuring jug
 bedpan or urinal
70
 gloves

Preparation
The test does not require anything other than normal urination. Generally, the patient is given
one or more containers to collect and store urine over a 24-hour period.
Procedure
1. explain procedure to the patient to seek consent
2. label the bottle with patient identifying information, the date and time the collection begins
and ends
3. instruct the patient to urinate, flush down the urine when he gets up in the morning
4. Afterward tell the patient to collect the rest of the urine in the special bottle for the next
24-hours storing it in a cool place or environment.
5. Instruct the patient to drink adequate fluids during the collection period.
6. Emphasize proper hand hygiene before and after each collection. Record each amount on
the intake and output sheet
7. Exactly 24-hours after beginning the collection ask the patient to void. This will complete
the specimen collection.
8. Record completion of time of the 24- hour urine collection
9. Ensure that the urine collection is sent to the laboratory with a request form and the
patient’s details as soon as possible.
10. Wash hands and clean the items used.

Random Urine Sample

A sample of urine collected at any time of the day. This type of specimen is most convenient to
obtain. This type of sample may be used to detect the presence of various substances in the
urine at one particular point of the day.
Equipment

 Clean dry container with lid

 Cotton ball or gauze and antiseptic solution
 Laboratory request form

Procedure
1. Explain procedure to patient and seek consent of understanding
2. Instruct the patient to clean the urethral area with the gauze and solution to prevent
external bacteria from entering the specimen
3. Let the patient void into the container
4. Label the specimen container with the patient identifying information and send to the lab
immediately

71
 5. Wash your hands and instruct patient to do it as well
6. Note the time the specimen was collected.
The same procedure applies to the collection of early morning urine. This specimen is collected
immediately the patient wakes up in the morning. It also done for other test like pregnancy test.

Cather Specimen Of Urine

Equipment

 Alcohol impregnated swab

 A 20 ml syringe
 Sterile specimen container
 Non tooth clamp
 Apron and gloves

Procedure
1. Explain the procedure to the patient
2. Provide privacy
3. Wash hands and dry thoroughly
4. Wear apron and gloves
5. If there is no urine present in the catheter tubing, clamp it below the sampling port for
15-20mins to allow urine to collect
6. Clean the sampling port on the tubing with the alcohol impregnated sab and allow to
dry
7. Insert the syringe into the sampling port and aspirate the required amount of urine.
8. Transfer the urine into the specimen bottle and close it tightly
9. Remove the clamp to allow free drainage of urine into the urine bag.
10. Make sure the patient is comfortable
11. Discard all items appropriately
12. Remove gloves, apron and wash hands
13. Label specimen and take to the laboratory together with a request form
14. Document the date and time of specimen collection in the patient’s record
Note: If the urine sample is being taken from an infant, the clean catch kit consists of a plastic
bag with a sticky strip on the end that fits over the baby’s genital area as well as a sterile
container.
Pour the urine into the sterile container.
After collecting a urine sample, it is evaluated in three ways: visual exam, dipstick test and
microscopic exam.
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Visual Exam
A lab technician examines the urine’s appearance. Urine is typically clear. Cloudiness or an
unusual odour can indicate a problem, such as an infection.
A. Colour: normal urine is amber or straw and may change depending on some conditions.
The colour becomes pale when a lot of water is taken.

B. Deposits: these are substances found in the urine when it is passed in

Into a container or specimen bottle. When it is settled the things found in it after the
urine has cooled down or has been left standing for some times are mucus (light fluffy
cloud), urates (settle at the bottom as pinkish), phosphates (usually of calcium and
magnesium)
and pus (the presence of pus gives the urine a fishy offensive odour)
C. Amount: the amount taken varies from time depending on the fluid taken. The average
is approximately 1100-1700ml in 24 hours. There may increase or decrease in the urine
depending on the patient’s condition and they are

1. Oliguria: is the name given to the excretion of decreased amount of urine passed within
24 hours
2. Polyuria: this is used to describe an increase above normal limits in amount of urine
passed.
3. Anuria: this means that no urine is being passed at all.

D. Specific gravity: this is the term used to describe the weight of a substance as compared
to the weight of an equal amount of distilled water. It is determined by using a
urinometer. The normal specific gravity varies from 1010-1025.

E. Odour: urine has a characteristic odour and if there are any abnormalities present it
shows a difference.

Acetone: it is usually a fruity sweet smell found in diabetes. Ammonia when the urine
has begun to decompose in the specimen glass.

F. Appearance: a hazy appearance depicts the presence of mucus and smoky due red blood
cells. Urine is usually clear and sometimes cloudy.

Dipstick Test
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A dipstick is a thin, plastic stick with strips of chemicals on it and is placed in the urine. The
chemical strips change color if certain substances are present or if their levels are above typical
levels. A dipstick test checks for:
 Acidity (pH): the pH level indicates the amount of acid in urine. The pH level indicates
a kidney or urinary tract disorder. The normal range from 5.0-7.0 with the average of
6.0. Urine is normally acid in reaction, but it becomes alkaline when left to stand for
some time.
 Concentration: a measure of concentration shows how concentrated the particles are in
your urine. A higher than the normal concentration often is a result of not drinking
enough fluids.
 Protein: low levels of protein in urine are typical. Small increases in protein in urine
usually aren’t for concern but larger amounts might indicate a kidney problem. The
abnormal amount of protein in urine is known as proteinuria. The test used is the
albustix.
 Sugar: the amount of sugar (glucose) in urine is typically low to be detected. Any
detection of sugar on this test usually calls for follow-up testing for diabetes. The
common test used to the presence of glucose is the clinitest. Glycosuria is the term used
to describe the presence of sugar/glucose in urine.
 Ketones: as with sugar any amount of ketones detected in your urine could be a sign of
diabetes and needs follow-up. When excessive amount of ketones bodies begins to be
appearing in urine this is known as ketonuria. Conditions that can lead to ketonuria
include uncontrolled diabetes, diets that are mostly fats.
 Bilirubin: is a product of red blood cell breakdown. Usually, bilirubin is carried in the
blood and passes into the liver where it is removed and becomes part of bile. Bilirubin
in your urine might indicate liver damage or disease.
 Blood: blood in urine requires additional testing. It may a sign of kidney damage,
infection, kidney or bladder cancer or disease disorders. The condition in which blood is
found in is called hematuria.
 Evidence of infection: either nitrites or leukocyte esterase products of white blood cells
in the urine might indicate a urinary tract infections.

Microscopic Examination
Sometimes performed as part of urinalysis this test involves viewing drops of concentrated
urine that is urine that has been spun in a machine and under a microscope. If any of the levels
are above average and they include

 White blood cells (leukocytes) might be a sign of infection.

 Red blood cells (erythrocytes) might be a sign of kidney disease, a blood disorder or
another underlying medical condition such as bladder cancer.

74
  Bacteria, yeast or parasites can indicate an infection. Yeast in the urine of female
indicate vaginal infection known as candida albicans and can also be present in
diabetic patient’s urine.
 Casts are tube shaped proteins that can be as a result of kidney disorders.
 Crystals that form chemicals in urine might be a sign of kidney stones.

Collection and observation of stools

Stool cultures play an important role in understanding and treating intestinal illness. It can
confirm the presence of harmful bacteria and can also show the treatments that may work to kill
an invasive organism.
Obtaining a specimen of faeces
Equipment

 Gloves and apron

 Specimen container and lid
 Clean bedpan and cover
 Wooden spatula
 Specimen bag
 Completed request form

Procedure
1. Discuss the test and procedure with the patient. Ask him to tell you when he feels the urge
to have a bowel movement.
2. Wear gloves and apron when handling any bodily discharge
3. Bedpan should be provided when the patient is ready. If the patient wants to urinate first,
provide the urinal for men and if woman give extra bedpan. Avoid mixing urine or
regular toilet paper into the sample.
4. With the use of the spatula, transfer a portion of the feces to the specimen container. Do
not touch the specimen because it is contaminated because the gastrointestinal tract is not
sterile
5. Immediately cover the specimen and label it with the patient’s name and the needed
information.
6. Fill the appropriate laboratory request form
7. Place the specimen in the specimen bag and send to the laboratory.
8. Ensure the patient is comfortable
9. Offer handwashing to patient
10. Dispose of feces and clean bedpan or commode if used
11. Remove gloves and apron and wash hands
12. Document the time stool was collected.

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Observation

Normal The stool appears brown, soft and well-formed in consistency.

The stool does not contain blood, mucus, pus, undigested meat fibers,
harmful bacteria, viruses, fungi or parasites
The stool is shaped like a tube.
Abnormal The stool is black, red, white, yellow or green
The stool is liquid or very hard
There is too much stool
The stool contains blood, mucus, pus, undigested meat fibers, harmful
bacteria, viruses, fungi or parasites
The stool contains low levels of enzymes such as trypsin

 When the stool is hard this means constipation

 When pale, bulky, frothy it implies poor fat digestion
 Semi solid means digestion upset and mild diarrhea
 Watery stools mean bacterial infection after taking purgative
 Flattened and ribbon like means obstruction in the lumen of the bowel
 Rice water stool means cholera
With the colour
 Black/dark stool indicates bleeding in the upper GIT
 White means there was examination of the intestine done that is barium meal
 Bright red indicates bleeding in the digestive tract, piles
 Fresh blood, mucus clay means jaundice or obstruction of bile flow, amoebic
dysentery.

Collection And Observation of Vomitus

When the muscles of the stomach are irritated the contents of the stomach are ejected as
vomitus. Vomiting is the manifestation of many conditions and can have serious consequences
including electrolyte depletion, malnutrition, dehydration, and aspiration pneumonia.
When observing vomitus, the following should be noted
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  What is the content of vomitus? Does it contain partially digested food or resembled a
clear watery fluid or a yellow or green sticky fluid
 Red blood cells indicates that the bleeding began shortly before vomiting. If the blood is
black or appears dark brown and has the texture of old coffee grounds, then it means the
blood is in the stomach for a longer time.
 If the vomitus smell foul like feces make the note of the fact of the smell.
 When did the person last had a meal?
 Is the vomitus projectile that is forcefully ejected? It often travels several feet and is more
common in children than adults. It can be a symptom of congenital hypertrophic of pyloric
stenosis in infants. In adults it can be a symptom of poisoning or drug overdose where the
body aggressively trying to get rid of toxins. More so, it can also be as a cause of head
injury.
 Did the person feel any nausea or pain prior to vomiting? And whether or not the pain was
relieved by vomiting?
Collection of vomitus
Requirements
 Clean vomit bowl
 Special container with a lid
 Request form
 Gloves and apron
Procedure
1. Explain procedure to patient and how the specimen would be collected.
2. Keep a basin or bowl near or close the patient
3. If the patient is lying down, turn him on his side so that he will not choke or aspirate
4. Support patient when vomiting taking note if patient is having pains, whether the vomitus is
projectile or any irregularity in the vomiting.
5. Give water to patient to rinse the mouth after vomiting
6. Wash patient hands and change any soiled clothing or linen
7. Make patient comfortable in bed
8. Remove vomit bowl to sluice end
9. Then you observe the vomitus for any abnormalities
10. Save the vomitus, measure and record in the input and output chart
11. If some is to be taken to the lab pour into the container and label to the laboratory
immediately for further investigation
12. Wash hands and disinfect the vomit bowl
13. Record the time the specimen was collected

Collection Of Sputum

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Sputum also known as phlegm is a mucus and cells from the airway lining, bacteria or other
material coughed up from the respiratory tract through the mouth in a productive cough.
Normal sputum is white.
It is important to note the time when most of the expectoration occurs, whether it is always
produced just rising from bed or after meal or after exertion.

Types Of Sputum and Indications

When you observe sputum, the following must be noted, check the color, consistency (frothy,
watery, tenacious, thick) and odor
 Red may indicate the present of blood(hemoptysis) this associated with a lot of diseases
 Frothy (white or pink-tinged, foamy, thin sputum) is associated with pulmonary edema
 Purulent (pus, yellow or greenish sputum often copious and thick) denotes an acute and
chronic infection
 Foul smelling is typical of anaerobic infection. This is associated with bronchiectasis, lung
abscess
If the sputum is discolored, you should find out if it clears with coughing.
Yellow sputum is produced in the morning may clear with the second or third cough.

Serving And Removal of Sputum Mug

Requirements
1. Sputum mug with lid
2. Container to obtain the specimen
3. Gloves and apron
4. Request form
5. Disinfectant e.g., para zone
Steps
1. Explain to the patient how to use the sputum mug
2. Give sputum mug to patient at the bedside together with the specimen container
3. Teach and tell patient how to expectorate into the specimen container and the rest into the
sputum mug which contain disinfectant
4. Remove sputum mug to sluice end and wash patient’s hands
5.
6. Label and send specimen to the laboratory
7. Examine the sputum whiles at the sluice end for any abnormalities e.g. blood
8. Estimate amount of sputum and record into the intake and output chart

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9. Empty sputum carefully into the sluice
10. Decontaminate sputum mug
11. Wash hands and document findings
12. Record the time the sputum was taken.

Disinfection And Disposal of Specimen

1. Stool
Disposal and disinfection of stools after collection depends on the condition of patient. If the
patient was suffering from conditions like typhoid fever, cholera, dysentery, it should be well
disposed and disinfect in the sluice room and sterilized well to prevent cross infection.
2. Urine
Urine that contains pathogens should be well disposed in the sewage. The urine should be
placed in a special container and mixed with a high disinfectant and the time for that should not
be less 4 hours. After disinfection the urine together with the disinfectant is sluice away.
If the urine does not contain any microorganism, the urine is disposed of at the sluice end and
the bedpan is first rinse in cold water then washed with soapy water and rinsed again with fresh
water. It is then allowed to dry for the next reuse.
3. Sputum
Most of the time sputum is collected into special containers and taken to the laboratory but if
depending on the patient’s condition excess is produced into the sputum mug, it is taken to the
sluice end and disinfected well and sterilized for reuse.
4. Vomitus
Special attention is given to vomitus depending on the patient condition. If the vomitus
contains pathogens the same way of disposal of feces is applied. If it does not contain any
microbes then it is rinse in cold water, washed in hot soapy water with a brush then rinse again
in fresh water and then allow to dry or sterilized.

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 CHAPTER 3
3.0 PRINCIPLES OF ASEPSIS
Asepsis or aseptic means the absence of germs, such as bacteria, viruses and other
microorganisms that can cause disease. Health care professionals use aseptic technique to
protect patients from infection.
Aseptic technique is a standard healthcare practice that helps prevent the transfer of germs to or
from an open wound and other susceptible areas on a patient’s body. The skin is the body’s first
line of defense against germs. A person is vulnerable to infection as soon as there is a break in
their skin, regardless of whether it occurs as a result of an accidental injury or surgical incision.
Aseptic technique helps prevent health care associated infections which is an infection that a
person acquires as a result of treatment from a healthcare professional. Common ones include:

 Catheter associated- urinary tract infections

 Central line associated blood stream infection
 Surgical site infection
 Ventilator associated – pneumonia

Using aseptic technique prevents the spread of infection by harmful germs. Healthcare
professionals use aseptic technique when they are
 Performing surgical procedures
 Dressing surgical wounds or burns
 Suturing wounds
 Using instrument to conduct a vaginal examination
 Inserting a urinary catheter, wound drain, intravenous line, or chest tube
 Delivering babies
 Administering injections
 Performing biopsies

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A. MEDICAL ASEPSIS
Medical asepsis also known as “clean technique” reduces the number and transmission of
disease causing microorganisms after they leave the body but doesn’t necessarily eliminate
them.
It is used to care for clients with infectious diseases, to prevent reinfection of the client and to
avoid spreading infection from one person to another or throughout the facility.
The core medical aseptic practices include the following:
1. Handwashing
2. Wearing appropriate personal protective equipment (PPE) e.g. gloves, gowns, masks,
face shields, hair and shoe covers
3. Disinfecting articles and surfaces
4. The use of antiseptics
5. Cleaning the environment

1. Hand hygiene
This should be performed before any procedure and after. Hands can be decontaminated by
washing with soap and water or using alcohol-based hand rub. Hand hygiene must be
performed before preparation of the sterile equipment to avoid contamination of the equipment
and need to be repeated after the procedure.
2. Use of gloves and aprons
The use of sterile and single use nonsterile gloves depends on the procedure being done and
must be worn appropriately to prevent infections. It must be worn immediately before
beginning a procedure and removed carefully after a procedure has been done.
A clean disposable apron provides an ideal barrier between potentially contaminated uniforms
and the procedure, reducing any contamination that may arise from the procedure.
3. Environment
The procedure should be carried out in a location that maintains the patient’s privacy and
dignity such as treatment room, at the bedside with curtains drawn. The procedure area should
be prepared by closing windows, turning off fans, avoiding any bed making in proximity and
this is done to reduce the risk from air borne dispersal of microorganisms.
4. Maintaining a sterile field
During the procedure the sterile fields needs to be maintained this can be achieved by careful
opening of the sterile packets to avoid contamination of the sterile equipment and the sterile
surfaces of the inside packaging.
5. Equipment disposal

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 At the end of the procedure all waste must be disposed of in the appropriate waste stream bin
such as a healthcare waste bin. Sharps including needles, suture cutters, and blades must be
disposed of at the point of use in an approved sharps container. Aprons and gloves should also
be disposed according to hospital protocols and safely.
Principles Of Aseptic Technique

Action Rationale
Hand hygiene Remove transient micro-organisms from the hands
Safe storage of equipment Prevent damage to the sterile equipment, preserve
sterility of the equipment and prevent microbial
contamination
Cleaning the procedure trolley or tray Reduce microbial contamination
Preparation of equipment Prevent microbial contamination of sterile
equipment
Personal protective equipment (PPE) Aprons provide protection from potential
contamination from the healthcare workers (HCW)
uniform and the procedure and protect also the
HCW from potential contamination from the
procedure
Nonsterile gloves provide protection for the HCW
from contamination from blood and body fluids
that may contaminated the hands
Sterile gloves protect key sites from potential
microbial contamination from the HCW’s hands.
Preparation of the environment Reduce microbial contamination during the
procedure
Preparation of patient Gain informed consent and reduce anxiety
Waste disposal Prevent contamination of the environment
Documentation Provide essential communication and meet the
standards of nursing.

B. SURGICAL ASEPSIS
Also known as aseptic/sterile technique eliminates microorganisms before they can enter an
open surgical wound or contaminate a sterile field.
Aseptic technique includes sterilization of all instruments, drape and Objects that could
possibly have contact with the surgical wound or field. All health care providers and staff who
have contact with the sterile field perform a surgical hand scrub with an antimicrobial agent
before donning a surgical gown and gloves.

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Surgical asepsis is always practiced in
 Operating rooms
 Special procedure or diagnostic areas
 Burns unit
 Labor units
It is also used during invasive procedures at the bedsides such as inserting chest tube, central
lines, and catheters.
All surgical procedures are ideally performed under sterile conditions. Sterile technique is
designed to prevent the transmission of microorganisms into the body during surgery or other
invasive procedures. General principles of sterile technique should be familiar to all personnel
working in and around the surgical environment. These principles include:
 Use only sterile items within a sterile field
 Sterile(scrubbed) personnel are gowned and gloved
 Sterile personnel operate within a sterile field (sterile personnel touch only sterile items
or areas, unsterile personnel touch only unsterile items or areas)
 Sterile drapes are used to create a sterile field
 All items used in the sterile field must be sterile
 All items introduced onto a sterile field should be opened, dispensed, and transferred by
methods that maintain sterility and integrity
 A sterile field should be maintained and monitored constantly
 Surgical staff should be trained to recognize when they have broken technique and
should know how to remedy the situation.

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 CHAPTER 4
4.0 BASIC CONCEPTS OF HOMEOSTASIS
Homeostasis is the ability of a system or living organism to adjust its internal environment to
maintain a stable equilibrium such as the ability of warm-blooded animals to maintain a
constant body temperature.
Homeostasis can also be defined as any self –regulating process by which an organism tends to
maintain stability while adjusting to conditions that are best for its survival.
Homeostasis is important to maintain and sustain life. Without these homeostatic mechanisms
to ensure that the innate variables are kept within the optimal or suitable values, there would be
instability in the body and the system would not be able to function well.
Components
The human body would not be able to function well if there is a prolonged imbalance in the
internal physical conditions and chemical composition.
Variables such as body temperature, pH, sodium level, potassium level, calcium level and
blood sugar have to be kept within the homeostatic range. The homeostatic range is defined as
the allowable upper and lower limits for a particular variable.
In order for the body to keep these variables within efficacious limits, various regulatory
mechanisms are employed and each of them is comprised of three general components. They
are
1. A receptor
2. A control centers
3. An effector
A receptor
The receptor as the name implies is the part of homeostatic system that receives information
regarding the status of the body. It monitors and perceives the changes in its environment both

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the internal and external. It is in the form of sensory nerve terminal that receives the
information (stimulus) and then responds by producing a nerve impulse according to the type,
presence/absence or extent of stimulation. Examples of receptors in the body are
photoreceptors, olfactory receptor cells, auditory, gustation, thermoreceptors, and nociceptors.

Control Centers
The control centers pertain to the homeostatic component that processes impulses relayed by
the receptors. It is also the component in a feedback system that compares the value to the
normal range. If the value deviates too much from the set point, then the control center
activates an effector. Examples are the respiratory center and the renin angiotensin system.
The Effectors
The effectors are the target of the homeostatic response that would bring about the reversion of
conditions to the optimal or normal range. Effectors are muscles and glands.

Homeostatic Mechanisms
Homeostatic mechanisms that respond to a deviation of a system or a process from its regular
or normal state maybe in a form of a looping mechanism called feedback mechanism that can
be positive or negative.
Positive feedback maintains the direction of the stimulus. It tends to accelerate or promote the
effect of the stimulus. It can also be a mechanism in which the effect of the response to the
stimulus is to shut off the original stimulus or reduce its intensity. Examples are labor
contractions, blood clotting.
Negative feedback is a self –regulatory system and is employed in various biological systems.
It reverses the direction of the stimulus and tends to inhibit the source of stimulus or slow down
the metabolic process. Examples include thermoregulation, blood glucose regulation, and
osmoregulation.

Physiology Of Homeostasis In Relation To Health

The human body maintains itself in a stable state through homeostasis which is the central to
life. Understanding of homeostasis and the states that are optimal for the body cells can be used
in healthcare. This can be done empirically through the observation of humans in health and ill
health. The objective measurement that can be used is the vital signs. Which include
temperature, heart rate, pulse, blood pressure, respiratory rate, oxygen rate. Determining which
vital signs are outside their normal range helps health professionals to locate and diagnose the
underlying cause, so measuring vital signs is the basis of finding out what is wrong.

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In ill health homeostasis is challenged and vital signs go out of their normal range. Clinical
interventions are an attempt at restoring vital signs to their normal range and so restore
homeostasis. And this is achieved through clinical decisions and treatment.

Homeostatic Disorders
If positive and negative feedback loops are affected or altered, homeostatic imbalance and
resultant complications can occur. Many diseases are a result of homeostatic imbalance, an
inability of the body to restore a functional, stable environment.
Disease is any failure of normal physiological function that leads to negative symptoms. While
disease is often a result of infection or injury, most diseases involve the disruption of normal
homeostasis. Anything that prevents positive or negative feedback from working correctly
could lead to disease if the mechanisms of disruption become strong enough.
Aging is a general example of disease as a result of homeostatic imbalance. As an organism
ages, weakening of feedback loops gradually results in an unstable internal environment.
Examples include diabetes which is a metabolic disorder caused by excess blood glucose levels
and is a disease caused by failed homeostasis. Another example is heart failure as a result of
high blood pressure and enlargement of the heart (that is when the heart becomes too stiff to
pump blood effectively).
Examples of homeostasis:
1. Positive feedback
Labor contractions: initial contraction of the uterine muscle leads to further contractions.
Rather than inhibiting the contraction, the body tends to produce more contractions, and this is
positive feedback.
At labor, the posterior pituitary gland releases oxytocin which stimulates muscle contraction.
The hormone oxytocin made by the endocrine system stimulates the contraction of the uterus
which produces pain sensed by the nervous system. At child delivery oxytocin release is
further augmented, intensifying muscle contractions until the neonate is pushed outside the
birth canal.
Thermoregulation
Temperature control is a negative feedback mechanism. Nerve cells relay information about
body temperature to the hypothalamus. The hypothalamus then signals several effectors to
return the body temperature to normal 37 degree Celsius (the set point). The effectors may
signal the sweat glands to cool the skin and stimulate vasodilation so the body can give off
more heat.

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If the body temperature is below the set point, muscles shiver to generate heat and the
constriction of blood vessels helps the body retain heat. This example is very complex because
the hypothalamus can change the body’s temperature set point such as raising it during a fever
to help fight an infection.
When homeostasis is interrupted, your body can correct or worsen the problem based on certain
influences. They are internal influence which is heredity (genetics) and external influences
which is based on lifestyle (nutrition, physical activity and mental health) and environmental
exposure.

CHAPTER 5
5.1 BASIC PRINCIPLES UNDERLYING HEALTH AND DISEASE IN
NURSING CARE
A. INTRODUCTION TO NURSING PROCESS
A process is a series of steps that follow a logical sequence. The term nursing process is widely
accepted to designate a series of steps that the nurse takes in planning and giving nursing care.
It provides a logical framework on which the nursing care is based.
It is defined as a systematic problem- solving approach for giving comprehensive nursing care.
It can also be defined as an orderly, systematic way of identifying the client’s problems,
making plans to solve them, initiating the plans, or assigning others to implement it and
evaluating the extent to which the plan was effective in resolving the problems identified.
Characteristics of nursing process
1. It is a framework that enables a nurse to give nursing care to individuals, families, and
communities
2. It is dynamic. Each step-in nursing process flows on to the next step. In some nursing
situations all the stages occur almost simultaneously.
3. It is interpersonal. Human being is always the heart of nursing, in this, nurses are client
centered and not task oriented.
4. It is outcome- oriented. The client benefit from continuity of care and each nurse’s care
moves the clients closer to outcome achievement.

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5. This process is universally applicable in all nursing situations and can be used throughout
the life span.

Phases Of Nursing Process

The nursing process is a systematic method that helps the client and the nurse to carry out the
following:
1. Assessment in which the need for nursing care is determined
2. Nursing diagnosis about actual and potential problem
3. Outcome identification and plan of action based on that.
4. Implementation of planned care
5. Evaluation to determine the achievement of planned goals
Assessment
It is a deliberate, systematic and logical collection of subjective and objective data that are
helpful to identify and define problems of the client before the nurse proceeds to plan the care.
A comprehensive assessment is holistic and includes physical examination, health history,
psychological, sociocultural, emotional and spiritual factors that affect the client’s health.
Purpose of assessment

 It helps in gathering data about the client (individual, family or community)

 It is used as a data for diagnosing, identifying outcomes, planning and implementing care.

Reason for assessment

a. To gather baseline information about the client
b. To help identify the client’s health status and the ability to manage the problems and need
for nursing care.
c. To help identify client’s strengths based on which to plan individualized holistic care.
d. Help bring about positive changes in the client’s health status
e. Provide data for diagnosis

Types Of Assessment
1. Initial assessment: this involves comprehensive nursing assessment including client’s
history, general appearance, physical examination and vital signs
2. Focus assessment: is a detailed nursing assessment of specific body system relating to the
presenting problems or current concerns of the client, this may involve one or more body
systems
3. Time- lapsed assessment: it is performed after initial assessment to compare current status
with baseline data previously obtained.

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4. Emergency assessment: it is performed during physiological and psychological crisis to
identify life threatening problems.

Assessment Skills
Assessment involves recognizing and collecting cues. Cues are pieces of information about a
client’s health status and can be overt or covert (subjective and objective). The clinical skills
utilized for assessment include the following.
Observation, interviewing, physical examination and intuition.
Assessment activities
Collection of data is a process of compiling information about the client. Both subjective and
objective data are collected.
Subjective data or symptoms or covert cues are the client’s feelings and statements about his or
her health problems
Objective data or signs or overt cues are observable, perceptible and measurable data.
Sources of data: there are two main important sources of data collection. Primary source is the
client himself and secondary source includes family members or significant others. Tertiary
source is data which is gathered from the health care providers and patient’s folder.

Nursing Diagnosis
This is the second phase of the nursing process. Diagnosis is the clinical act of identifying the
problems
Components of nursing diagnosis
A. Diagnostic label: is the name of the nursing diagnosis. It describes the essence of the
problem using as few words as possible. For example, stress incontinence
B. Qualifiers: are words used to give additional meaning to a nursing diagnosis. Examples
altered, impaired, deficient, excessive, dysfunctional, disturbed, ineffective, acute, chronic
C. Definition: describes the characteristics of human response under consideration
D. Defining characteristics are major and minor clinical cues that validate the presence of an
actual nursing diagnosis
E. Risk factors are identifiable intrinsic and extrinsic characteristics of the client e.g. risk for
infection
F. Related factors: they describe the conditions, circumstances or etiologies that contribute to
the problem. E.g. fluid volume deficit related to vomiting.

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Outcome criteria/ identification
Outcome criteria refers to documenting specific, measurable, attainable, realistic and time
bound goals.
Purpose

 Provide individualized care

 Encourage client participation
 Plan realistic and measurable care
 Encourage involvement of support people

Implementation
This is the action phase of the nursing process. It is the actual initiation of the plan and
documenting of nursing actions. Implementing is mean to carry out, to perform, to intervene or
to do something. The nursing activities may be carried out by the nurse, or it may be delegated
to a group of nurses but interventions can be independent or dependent.
Purpose
Provide technical and therapeutic nursing care required to help the client achieve an optimum
level of health
Activities of implementation
1. Reassess the client
2. Set priorities: as the client’s condition changes, priorities also change. Nursing intervention
must be carried out based on priority needs
3. Perform nursing interventions: nurses must carry out the nursing interventions listed in the
plan for each client
4. Document nursing action: after implementing the plan, it must be documented in the
client’s record
To help carry out the implementation phase successfully, nurses must have the following skills:
 Intellectual skills
 Interpersonal skills
 Technical skills
 Evaluation
Evaluation is the process of determining the extent up to which the goals of nursing care have
been attained. It refers to rating, grading, and judging.
Purpose
1. Gather subjective and objective data to make judgements about the nursing care delivered
2. Evaluate the extent of achievement of goals and resolution of problems
3. Decide about the quality of nursing care and the beneficial effects on the client’s health
status
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4. Form the strong basis for the revision of nursing care plan.
Evaluation can concentrate on the improvement of quality of care given to the clients. Quality
improvement means measuring the extent to which standards have been achieved.

B. ADMISSION, TRANSFER, AND DISCHARGE

Admission of a patient means allowing and facilitating a patient to stay in the hospital unit or
ward for observation, investigation and treatment of the disease he or she is suffering from.
Purpose of admission procedure

 To provide immediate care

 To provide comfort and safety to the patient
 To be ready for any emergency
 To assist the patient in adjusting to the hospital environment
 To involve patient and family in care
 To assist proper discharge planning of care
 To receive the patient in ward for admission according to his condition
 To obtain information about the client so as to establish therapeutic nurse patient
relationship.

Types Of Admission
Routine admission: clients are admitted for investigations and planned treatments and for
surgeries e.g. diabetes, hypertension. The nurse receives the patient, and the family as follows
1. Welcome patient and family nicely with a smile and making them comfortable by providing
them with seats
2. Introduce yourself and any staff present
3. Collect necessary documents, admission notes and any other information from
accompanying nurse
4. Identify and confirm patient by name, particulars and reassures him/her
5. Send patient to bedside and introduce him to other patients near him
6. Check and record vital signs – temperature, pulse, respiration, and blood pressure
7. Administer urgent prescribed drugs if necessary
8. Assist patient to change into his night dress or pyjamas
9. Take care of patient valuable according to the institution’s policy
10. Let patient or legal guardian sign consent form for treatment etc where necessary
11. Explain national health insurance system to patient and relatives
12. Inform relatives about visiting time and allows them to see patient and say goodbye
13. Orientate patient to ward and its annexes
14. Enter patient name into admission and discharge book and into the daily ward state

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15. Document in nurse’s notes

Emergency/trolley admission:
Patients are admitted for acute, an emergency condition which requires immediate treatment
like burns, drowning, road accidents, fall, heart attack. Sometimes patient may walk into the
ward but treated as emergency. Emergency trays or equipment are always made ready to avoid
rush. These include oxygen, suction, drip stand as well as bed to suit the condition.
The admission process is the same as in planned but with a little difference.

The steps are:

1. Welcome the patient and family as in the planned admission and follow them to the bedside
2. Collect the admission documents from the accompanying nurse
3. Reassure patient and relatives
4. Quickly assess the general condition of the patient
5. Put patient into prepared bed clothes
6. Assess patient by:
 Checking and recording vital signs
 Skin and other parts of the body
 Mental status
 Level of consciousness

 Administer emergency drugs as prescribed by physician

 The rest of the steps is the same as the planned admission.

Discharging The Patient

Discharge is a preparation of a patient and discharge records to leave the hospital.

Purpose
1. To ensure continuity of care to the patient after discharge
2. To assist the patient in discharge process
Guidelines
1. Discharge to home. The discharge to home is initiated by the doctor who advises the
patient that he is well enough to leave the hospital and continue care at home.
2. Discharge to another hospital or another unit within the hospital (referral). When a
patient is to continue treatment in another unit within the hospital or in another hospital.
3. Discharge against medical advice (DAMA): when a patient or family is not satisfied with
the treatment or care given and wants to leave the hospital against the medical advice, in
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 such cases the patient of the relative is asked to sign a statement that he is going or taking
the patient on his own will and responsibility
4. Absconding: is when the patient leaves the hospital against the medical officer’s advice by
running away without them knowing. This can happen depending on the patient’s
condition (mental patient or disoriented patient) or to avoid medical bills or medications.
When this happens, the nurse should inform the ward in charge and a process is followed
by reporting to the hospital authorities by providing the name of patient, sex, age,
diagnosis and address and sometimes the police is informed about the patient by the
hospital administration.
5. Death: is when the patient dies on the ward during admission and is recorded in the
admission and discharge book as discharged.

Discharging A Patient From The Hospital

1. Inform patient about discharge
2. Educate patient and relatives on the need to continue treatment and follow up care
3. Ensure that patient’s hospital bill is worked out and given to patient’s relatives early for
early settlement
4. Ensure that discharged papers are signed by the doctor
5. Make that the hospital bills are settled, and receipt number recorded in the admission and
discharge book and given back to patient
6. Direct relatives to collect drugs for patient from the pharmacy
7. Explain how drugs should be taken
8. Help patient to pack his/ her belongings
9. Hands over any valuables in the nurse’s custody to the patient’s relatives and records in the
nurse’s note witnessed and signed by the charge nurse
10. Remind patient and the relatives about the review date, stresses on its importance and tell
them where to report
11. Bid them goodbye
12. Remove linen and clean the bed and lockers of patient.

C. REHABILITATION AND CONTINUITY OF CARE

Continuity of care is an ideal in which health care is provided for a person in a coordinated
manner and without disruption despite all the complexities of the health care system and the
involvement of different practitioners in different care settings. Also, all people involved in a
person’s health care, including the person receiving care, communicate and work with each
other to coordinate health care and to set goals for health care.
When continuity of care is missing people may not adequately understand their health care
problems and may not know which practitioner to talk to when they have problems or questions

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Rehabilitation
Is a special health care services that help a person regain physical, mental, and/or cognitive
(thinking and learning) abilities that have been lost or impaired as a result of disease, injury, or
treatment. Rehabilitation services help people return to daily life and live in a normal or near
normal way.
These services may include physical therapy, occupational therapy, speech and language
therapy, cognitive therapy, and mental health rehabilitation services.

CHAPTER 6
6.0 DOCUMENTATION AND ITS LEGAL IMPLICATIONS IN NURSING
PRACTICE
Document is described as any written or electronically generated information about a patient
status or the care or the service provided to that patient.
Nursing documentation is the record of nursing care that is planned and delivered to individual
client. Nursing documentation is varied, complex and time consuming depends on the severity
of the patient condition. It is the process of communicating in written form about essential fact.
Records and reports are essential components of documentation.
Records is a written communication that permanently document the information relevant to a
client’s health care management. It is a valuable source of data for all members of the health
care team.
Reports may be oral or written form of documentation. It can also be an oral, written or
computer-based communication intended to convey information to other.

Purpose Of Documentation
 Communication: The primary purpose of documentation of client care is the
communication among health care professional to promote continuity of care among
departments throughout 24hours.
 Quality assurance: It provides substantiation of quality care.

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 Legal accountability: It serves as legal document. It may be used as evidence in court
proceedings.
 Research: Nursing and health care research is often carried out by studying client records.
 Diagnosis: Documents helps in diagnosis of patient’s condition
 Evaluation: Patient condition progress towards disease condition will be evaluated based
on his or her record.
 Education: Members of the health team including students utilize these records as an
educational tool.
 Vital statistics: Client records, registers and reports furnish the vital statistics.

Principles Of Nursing Documentations

1. Accuracy in charting: Be specific and definite in using words or phrases that convey the
meaning you wished expressed. Words that have ambiguous meanings and slang should not
be used in charting.
Chart’s objective facts not your interpretations or opinions. Place the complaint of the client
in quotation marks to indicate that it is his statement.
2. Date and time: Document date and time of each recording

3. Correct spelling: It is essential for accuracy in recording

4. Appropriateness: Record only information that pertains to the client’s health problems and
care.

5. Legal protection: Accurate complete documentation will give legal protection to the nurse,
other health professionals and the client.

6. Accuracy: Client’s name and identification data must be written on each page of the
client’s records and entries must be correct.

7. Brief: Only standard medical and nursing terminology and community recognized
abbreviations and symbols should be used.

8. Completeness: Document all information necessary to explain the events in a shift. Anyone
reading the document should have a clear picture of what took place.
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9. Omissions: Blank spaces are not to be left on the chart and avoid writing outside the lines
of the charting format.

10. Confidentiality: Information within the chart is often of a personal matter as well as legal
evidence of the care provided and should be available for the necessary health team
members only.

11. Standard: Spell correctly, use proper grammar and put signature. Affix signature, place at
the end of charting at the right-hand margin of the nurses’ notes
Sign each entry with your full name and status e.g. SN for student nurse, RN for rotation nurse
In case of error, correct errors by drawing a single horizontal line through the error, write error
above the line then sign against it. No ink eradication, erasers, or use of occlusive materials.

Documentation Format
The nurse can use the SOAPIER format, APIE charting, focus charting and computer assisted
charting.
SOAPIER formats include:
S - which stands for subjective (what the patient tells you the nurse)
O- Objective what the nurse observes
A – Assessment (the critical analysis and evaluation or judgement of the patient condition
P- Plan what the nurse is going to do about patient’s condition
I -which means implementation that is various interventions to use
E- Evaluation (patient’s response towards nursing care)
R- Revision = changes the treatment if plan did not work.
APIE means assessment, problem identification, intervention, and evaluation.
Focus charting only focus on nursing diagnosis, patient problem, signs and symptoms and it has
three components: data, action, and response
Computer assisted charting: notes are always legible and easy to read, quick communication
among departments about patient’s needs and also reduces documentation time.

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Types Of Records
1. Individual staff records which are a separate set of record provided for staffs, giving details
about their career development, absences
2. Patients’ clinical records is the record of events in the patient illnesses, progress in the
recovery of patient and the type of care given by the hospital
3. Ward record include duty roster, staffs leave records, admission records, discharge, transfer,
medicine and inventory and stock records.
4. Administrative records include legal documents for the patients with poisoning, rape,
assault, burns etc., research or statistics data, audit and nursing audit, personal performance,
and quality of care records
Records maintained by nurses include vital signs chart, intake and output chart, nurse’s notes.

Reporting
It facilitates clinical decision making, continuity of care and co-ordination among health team
members. The reports used in hospital setting usually are:
1. Change of shift report
2. Transfer reports
3. Incident reports
Nurses’ responsibility for record keeping and reporting
a. No individual sheet be separated
b. Keep under safe custody of nurses
c. Strangers are not permitted to read records
d. Not accessible to patients and visitors
e. Records are not handed over to the legal advisors without written permission of the
administration
f. Handed carefully not destroyed
g. Identified with bio-data of the patients such as name, age, admission number, diagnosis
etc.
Legal Implications of Documentation
Documentation provides important legal protection. Admissible in court, the patient’s medical
record must be documented in an accurate, complete, systematic, logical, concise, and timely
manner. Courts will view the documentation in the medical record as proof and verification to
patient care. By showing that the individual under your care received quality and equal care, a
well-documented record can and will most likely protect you legally.
The medical record is a legal document and is regarded as highly confidential. In the event of a
medical malpractice case, the medical record may be used to provide the court with evidence
about patient’s condition and treatments. For this reason, all documentation should be neatly
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written and be read. Avoid words that are unnecessary or very long and abbreviation of words
should be in their standard forms. Care that was provided by someone should not be
documented by you but rather the person himself. If there is any problem, you will be held
liable.
The following mistakes can cause legal problems

 Accuracy of documentation
 Documentation not fully completed
 Failure to record prevention efforts
 Failure to treatments and care
 Failure to record refusal of care/ refusal of orders
 Failure to record family’s refusal to accept care provided to patient
 Incomplete incident reports (do not note incident report in a chart)
 Meddling with a medical record

CHAPTER 7
7.0 PAIN ASSESSMENT AND MANAGEMENT
Pain is defined as unpleasant sensory and emotional experience arising from actual or potential
tissue damage. Pain is whatever the experiencing person says it is, existing whenever he/she
says it does. Pain is one of the most common reasons people seek health care and one of the
most widely under treated health problems.

Types Of Pain
The sensation of pain involves communication between your nerves, spinal cord, and brain.
There are different types of pain depending on the underlying cause. They are:
1. Acute pain
Is a short-term pain that comes on suddenly and has a specific cause, usually tissue injury.
Generally, it lasts for fewer than six months and goes away once the underlying cause is
treated. Acute pain tends to start out sharp or intense before gradually improving. Common
cause of acute pain includes broken bones, surgery, labor and birth, cuts and burns

2. Chronic pain
Pain that lasts for more than six months even after the original injury has healed. Chronic pain
can last for years and range from mild to severe on any given day. While past injuries or
damage can cause chronic pain, sometimes there is no apparent cause. Without proper
management chronic pain can start to impact one’s quality of life and develop symptoms of
anxiety and depression. Other symptoms that can accompany chronic pain include tense

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muscles, lack of energy and limited mobility. Some common examples of chronic pain include
frequent headaches, low back pain, and nerve damage pain.

3. Nociceptive pain
Is the most common type of pain and it is caused by stimulation of nociceptors which are pain
receptors for tissue injury. Nociceptors are found everywhere in the body especially in the skin
and internal organs. They send signal to the brain when there is any injury or inflammation.
Nociceptive pain can either be chronic or acute and can further be classified as being visceral or
somatic.

Visceral pain results from injuries or damage to your internal organs. It can be felt around the
trunk, chest, abdomen, and pelvis. It is mostly difficult to pinpoint the exact location of this
pain.
Is often describe as pressure, aching, squeezing, and cramping. Other symptoms include nausea
or vomiting as well as changes in body temperature, heart rate or blood pressure. Examples of
visceral pain include gallstones, appendicitis.
Somatic pain results from stimulation of the pain receptors in your tissues rather than your
internal organs. This includes the skin, muscles, joints, connective tissues, and bones. It is
easier to point the location of the pain and usually feels like aching and gnawing sensation. It
can further be described as deep or superficial. Examples of somatic pain are bone fractures,
strained muscles, connective tissue disease such as osteoporosis, cancer that affects the skin or
bones, skin cuts, burns and point pains including arthritis pain.

4. Neuropathic pain
It results from damage to or dysfunction of your nervous system. This results in damaged or
dysfunctional nerves misfiring pain signals. It may also bring about pain in response to things
that aren’t usually painful such as clod air or clothing against the skin. It is described as
burning, freezing, numbness, and tingling, stabbing and electronic shocks. Common cause of
neuropathic pain includes diabetes, shingles, chronic alcohol consumption, accidents,
infections, facial nerve problems, spinal nerve inflammation or compression, chemotherapy
drugs, radiation.

Factors Influencing Pain

Many different factors influence the experience of pain which is different for everyone. These
include
 Age
 Gender
 Culture
 Ethnicity
 Spiritual beliefs
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  Socio- economic status
 Emotional response
 Support system

Guidelines On Pain Assessment

Pain is often referred to as the “fifth vital sign” and should be assessed regularly and
frequently. Pain is individualized and subjective therefore the patient self- report of pain is the
most reliable gauge of the experience. If the patient is unable to communicate, the family or
caregiver can provide input. Components of pain assessment include

History And Physical Assessment

This includes physical examination and the systems in relation to pain evaluation. Areas of
focus should include site of pain, musculoskeletal system, and neurological system. Other
components of history and physical assessment include:
1. Patient’s self- report of pain
2. Patient’s behavior and gestures that include pain e.g., crying, guarding etc
3. Specific aspects of pain: onset and duration, location, quality of pain (as described by
patient), intensity, aggravating and alleviating factors
4. Medication history
5. Disease or injury history
6. History of pain relief measures including medications, supplements

Functional And Psychological Assessment

This includes:
1. Reports of patient’s prior level of function
2. Observation of patient’s behavior while performing functional tasks
3. Patient’s goal for pain management and level of function
4. History of pain in relation to depression, abuse, chemical or alcohol use
5. Patient’s or family report of impact of pain on quality of life

Multidimensional Assessment
Many tools are available for an in- depth multidimensional pain assessment and this is
particularly important with patients that have chronic pain, mixed pain (acute and chronic) or
complex situations. Common examples of these tools include brief pain inventory which
provides patient input in describing pain and effects including psychosocial components.
McGill pain questionnaire where patients can use descriptors for their pain which provides
information about the experience and intensity.

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Common Pain Scales
These are a variety of pain scales used for pain assessment for patients from neonates through
advanced ages. The three most common scales used are

1. The numeric scale that is rating pain on the scale of 0-10. Is commonly used for adults and
children nine and above.

2. Wong- baker scale, this uses drawn faces for patients to express their level of pain. The
faces are rated with numbers from 0-10 and is commonly used with children three and
above. It can also be used for adults having developmental or communication challenges.

3. FLACC scale is an acronym for face, legs, activity, cry and consolability. This scale is
based on observed behaviors and commonly used for pediatric patients less than three years
of age.it also rated from 0-10.

Pain Management

It refers to the appropriate treatment and interventions developed in relation to pain assessment
and should be developed in collaboration with the patient and family.
Pain management strategies include pharmacological and non-pharmacological approaches.

Non-Pharmacological Treatment
Non-pharmacological interventions include
 Heat or cold as appropriate
 Massage
 Therapeutic touch
 Decreasing environmental stimuli e.g. sound, light, temperature
 Repositioning
 Relaxation technique
 Immobilization
 Psychotherapy or cognitive behavioral therapy
 Music therapy
 Distraction

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Pharmacological Treatments
The use of medications to treat pain is the common management use. Pharmacological
treatments include analgesics (acetaminophen), non- steroidal anti- inflammatory (NSAIDS)
examples include salicylates, ibuprofen, opioids e.g. codeine and topical agents like creams.

CHAPTER 8
8.0 BASIC PRINCIPLES OF WOUND DRESSING
Dressing is an essential element of standard wound care. The main purpose of wound dressing
is:

 Provide a temporary protective physical barrier

 Absorb wound drainage
 Provide the moisture necessary to optimize re-epithelialization

Precautions To Be Taken Before Wound Dressing

1. Ensure that sweeping and mopping of ward is completed at least an hour before dressing is
done.
2. There should be proper lightning system
3. All fans should be switched off
4. All equipment and instruments should be well sterilized and kept intact.
5. Masks should be worn by all staffs doing the wound dressing and talking should be less
6. Ward should be closed. No visitors should be allowed.

Dressing Of Wound In The Ward

Preparation of the dressing trolley

The dressing is prepared as follows
1. Put on mask
2. Wash hands and dry
3. Bath the trolley with soap and water
4. Rinse and dry
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 5. Clean with disinfectant e.g. spirit
Requirements
Top shelf
o 3 gallipot for lotion
o 2 pair of dressing forceps
o 2 pair of dissecting forceps
o Sinus forceps
o Probe
o Stitch scissors
o Covered bowl for cotton wool and gauze swabs
o Covered receiver for dressing towel
o Clip remover OR

A Dressing Pack Containing

1. 2 dressing forceps
2. Sinus forceps
3. Stitch forceps
4. Probe
5. Clip remover
6. 3 gallipot
7. Towel, gauze, and cotton wool swabs
Lower shelf
1. Bottles of lotions e.g. savlon, methylated spirit
2. Adhesive plaster
3. Scissors
4. Bandages
5. Covered receiver containing parazone 1: 10 for soiled instruments
6. Mackintosh with a cover
7. Receptacle for soiled dressings
8. gloves

Wound Dressing Without An Assistant

Steps
1. Explain procedure to patient and ensure privacy
2. Prepare and take trolley to the bed side of patient
3. Make patient comfortable by position and protect the bed with mackintosh and towel
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4. Pour out lotions into the gallipot and remove plaster or bandage
5. Remove soiled dressing with dissecting forceps or disposable glove hand and discard
6. Wash hands and dry
7. Wear sterile gloves if instruments are not going to be used depending on the wound.
8. Clean wound with swabs soaked in normal saline using sterile forceps or gloves
9. Clean the clean starting from the wound outward (inside out) using a swab only once and
discard
10. Clean wound with series of swabs till it is clean
11. Apply sterile dressings and secure in place with strips of plaster or a bandage
12. Make patient comfortable in bed and commend him for his cooperation
13. Remove screen and discard trolley
14. Decontaminate, clean and sterilize instruments
15. Remove gloves, wash hands and report on findings to the in charge and write in the nurse’s
note.

Wound Dressing with An Assistant

Requirements the same as discussed above
Steps
1. Explain the procedure to patient and then ensure privacy by screening
2. Put on a mask and send prepared trolley to the bed side
3. Call for an assistant and ask to wash hands and dry
4. Wash hands, dry and put on sterile gloves if instruments are not to be used. Ask assistant
to
5. Put patient into comfortable position
6. Adjust bed clothes and place mackintosh and towel
7. Remove soiled dressings with disposable gloves and cover with a single layer of gauze
8. Wash hands and dry again
9. Pour lotions into the gallipots
10. Remove plaster and bandage
11. Clean wound with swabs soaked in antiseptic lotion (normal saline) in the same process as
discussed above.
12. After application of sterile dressings, the assistant can apply strapping of plaster or
bandage
13. Inform patient about the state of the wound
14. Make patient comfortable in bed and thank him for his cooperation
15. Remove screen and discard trolley
16. Decontaminate, clean and sterilize instruments
17. Wash hands, record and report on the state of the wound.

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 CHAPTER 9
9.0 ADMINISTRATION OF MEDICATION
MEDICATION
It is a drug used to diagnose, cure, treat or prevent disease.
A. DOSAGE
A dosage is the amount of a medicine or drug that someone takes or should take and how often
they should take it. It can also be defined as the administration of a drug or agent in prescribed
amounts and at prescribed intervals.

The dosage of drugs prescribed is influenced by four main factors

1. The age of the patient
2. The body weight of the patient
3. The half -life of the drug that is the time it takes for the drug to do its work in the blood
stream, the time it will take to reach the blood stream, and this is sometimes affected by the
route of administration. For example, drugs that are taken through the oral route takes a
longer time to reach the blood stream to take an effect than drugs taken through the
intramuscular route and the amount given is larger.
4. The rate at which the drug is excreted or destroyed by the body.

When a drug is being prescribed, the prescriber notes two things

1. The maximum dose that can be given to a patient which can be safe without producing
signs of overdose
2. The minimum dose to be given to a patient to produce an effect
The administration of medicines is a fundamental nursing skill and requires complex
knowledge and skills to undertake safely and one of skills required is the ability to calculate
drug doses and rates of drug administration to administer them to patient as prescribed.

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 Medication errors are mostly frequently due to the wrong dose, omitted or delayed
medication or the wrong medication being administered. Evidence suggests that most
medication errors are caused by health professionals:
1. Not understanding the unit of measurement for medication
2. Using the wrong equipment for example the wrong size needle for injection
3. Making mistakes in their calculations that result in the wrong dose or rate of medicine
being administered.
To calculate and administer the correct dose of a medicine to a patient, nurses need to
understand the different measurements used for drug dosages in healthcare and able to
convert between different units of measurement. Drugs are generally measured according to
either:

 The weight of the drug (grams, milligrams and micrograms)

 The volume (milliliters or liters)
 Standardized international units
 Strength of solution, when a weight of a drug is dissolved in a volume of liquid
for example milligrams per milliliter
 Percentages when drug is 100 parts of a product
Converting of units of measurement
From the largest to the smallest
Kilograms (kg)
1kg = 1000grams (g)
1kg = 1000 000milligrams (mg)
1kg = 1000 000 000micrograms (mcg)
Or
1kg = 1000g
1g = 1000mg
1mg = 1000 mcg
The prescribed dose is always converted to the units of the available drug dose so that it is
easier to compare the prescription with how the medicines is labelled. For example, if the
prescription given for benzyl penicillin is 1.8g but the available vial for this drug is 600mg to
compare the dosages the same unit of measurement is required.
To convert 1.8g to the equivalent mg dose, it must be multiplied by 1000 to get 1800mg.
For solid oral doses such as tablets, capsules, this type of calculation is usually straight forward.
It can be calculated as prescribed dose divided by available dose for example if the prescription
is for 30mg of prednisolone and the available tablets are 5mg then divide 30 by 5 to get 6
which is the number of tablets to administer.
Calculating the volume to give, nurses have formula which is termed as the nursing formula
commonly known as mantra “what you want, over what you’ve got multiplied by what it is in
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 dose required by patient x volume of solution
Volume to administer=
dose available

For example, amoxicillin suspension 125/5ml and a patient is to be given 250mg, how many ml
should be given.

250 mg×5 ml
Volume to be given = = 10ml
125 mg

Rules For The Administration Of Drugs

Understanding the Rights of drug administration can help prevent many medication errors and
help guide the nurse to administer medications safely.
The rights of drug administration include
1. Right drug
This is the first right of drug administration done to check and verify if it’s the right name of
the drug prescribed. Some drugs look-alike and sound the same.
2. Right patient
Ask the name of the patient and check his/her ID band, also in the patient’s folder before giving
the medication. Even if you know the patient’s name, you will still need to ask just to verify.
3. Right dose
Check the medicating sheet and the doctor’s order before medicating. Be aware of the
difference between an adult and pediatric dose.
4. Right route
Check the order if it’s oral, IV, SQ, IM, etc and also safe for the patient.
5. Right time and frequency
Check the order for when it would be given and when was the last time it was given.
6. Right documentation
Make sure to write the time and any remarks on the chart correctly.
7. Right education and information

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 Provide enough knowledge to the patient of what drug he/she would be taking and what are the
expected therapeutic and side effects
8. Drug approach and right to refuse
Give the client enough autonomy to refuse the medication after thoroughly explaining the
effects.
9. Right history and assessment
Secure a copy of the client’s history to drug interactions and allergies
10. Right drug- drug interaction and evaluation
Review any medications previously given or the diet of the patient that can yield a bad
interaction to the drug to be given. Check also the expiry date of the medication being given.

B. ROUTE OF ADMINISTRATION
Drugs are introduced into the body by several routes. They may be

 Taken by mouth(orally)
 Given by injection into a vein (intravenously, IV), into the muscle (intramuscularly, IM),
into the space around the spinal cord(intrathecal), or beneath the skin (subcutaneously,
SC)
 Placed under the tongue (sublingually) or between the gums and cheek (buccally).
 Inserted into the rectum(rectally) or vagina(vaginally)
 Placed in the eye (by the ocular route) or the ear (by the optic route)
 Sprayed into the nose and absorbed through the nasal membranes (nasally)
 Breathed into the lungs usually through the mouth (by inhalation) or mouth and nose
(nebulization)
 Applied to the skin (cutaneously) for a local (topical) or body wide (systemic) effect
 Delivered through the skin by a patch(transdermally) for a systemic effect

Each route has specific purposes, advantages and disadvantages.

Oral route
Many drugs can be administered orally as liquids (mixtures), capsules, tablets, powder.
Because the oral route is the most convenient and usually the safest and least expensive, it is
the most often used.
However it has limitations that is most of the drugs has unpleasant smell or taste and also can
irritate the mucosal lining of the gastrointestinal tract.

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Administration of liquid medication and mixtures
Requirements
A tray or trolley should be set with:
o Drug to be administered
o Water in a jug
o Glass on a saucer all in a tray
o Spoons
o Towel and mackintosh
o Straw
o Patient’s folder/ treatment chart and pen

Procedure
1. Identify and explain procedure to patient
2. Ensure all drugs and medicines are on the trolley or tray
3. Assist patient in sitting position if possible
4. Lateral position can be given unless contraindicated
5. Spread the towel and mackintosh under chin across chest
6. Wash hands
7. Take patient’s folder and verify physician order
8. Read label on the bottle and compare with patient’s chart or medication list including the
expiry date
9. Thoroughly mix the medication by shaking before pouring
10. Remove the cap and place it upside down to avoid contaminating the inside of the cap.
11. Hold the bottle so that the label is next to your palm and pour the medication away from the
label
12. Hold the medication cup at eye level and fill it to the desired level. Pour away excess
mixture never return it to the bottle.
13. Before cupping bottle, wipe the tip with a paper towel. This prevents the cup from sticking.
14. Read the label a third time, compare with the chart and dose in the glass.
15. Carry the medicine to the patient on a small tray, a spoon maybe added for stirring if
necessary
16. Pour the drug into the patient’s own glass
17. Supervise patients to drink the drug
18. Assist helpless patients to drink their drug
19. Chart all drugs administered
20. Congratulate patient and serve patient water to rinse the mouth
21. Discard trolley
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22. Wash hands and document in the nurse’s note the time, date and name of medication given.

Administration Of Tablets
With the requirements and procedure is the same as the mixture but a mortar and pestle is
added to it in case the patient the patient cannot shallow the tablet but can drink when crushed
into powder form.

Injection
An injection is a way a administering a liquid to a person using a needle and a syringe. It’s
sometimes also called a ‘shot’. Injections are used to give a wide variety of different
medications such as insulin, vaccines.
There are four most frequently used types of injection

1. Intravenous (IV) injections

Is the fastest way to inject a medication and involves using a syringe to inject a medication
directly into the vein. IV infusions allow a set amount of medication to be administered in a
controlled manner over a period of time.
A small plastic tube called a catheter is typically inserted into the vein for an IV injection to be
administered through. An IV catheter is most commonly placed into the vein in the forearm,
back of the hand, antecubital fossa (the depression on the inside of the elbow joint), and ankle,
close to the foot (for small babies and neonates).

Intravenous drug administration

Requirements

 Alcohol impregnated swab

 Syringes, needles and diluents
 Normal saline to flush the cannula ( IV catheter)
 Sharps bin
 Prescription chart and prescribed medicines
 gloves
Procedure
1. Explain the procedure to gain consent co-operation
2. The patient should be resting in chair or bed
3. Examine the site of the cannula for any infection, discomfort, pain

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4. Send prepared items to the bed side
5. Wash hands and dry thoroughly
6. Put on gloves and check the medicine or any diluents against the prescription chart and
check expiry date
7. Prepare and calculate the dosage of the medicine to be given if is in powder it has be
diluted,
8. Flush the IV line with normal saline before giving the medicine and also this is done to
know the patency of the line
9. At the bed side check the medicine and the patient’s name against the prescription again
10. Adopt a comfortable position that allow easy access to the cannula site and face the patient
so that if there is any adverse reaction to the drug it can easy to be detected.
11. Slowly administer the medicine according to prescription through injectable rubber cap or
port till the medicine get finish
12. Administer the remaining normal saline that was used to flush the line earlier through the
cannula
13. Discard the needle and syringe into the sharp bin
14. Remove gloves and wash hands
15. Document and observe patient for any drug reaction and also chart in the medication sheet
and nurse’s note.

Intramuscular (IM) injection

IM injections are given deep into a muscle where the medication is then absorbed quickly by
surrounding blood vessels. The site for IM injection includes:
 Thigh- vastus lateralis muscle between the hip and knee
 Bottom- ventrogluteal muscle just below the hip on the side of the body
 Upper arm- deltoid muscle between the top of the shoulder and the armpit.
When selecting an injection site for IM injection it’s important to pick one that is:
a. A safe distance from the surrounding nerves, bones, and large blood vessels
b. Large enough for the amount of medication
c. Not the site of an injury, abscess or dying skin
d. Not a muscle that is emaciated or atrophied

Giving intramuscular injection

Requirements
A tray with
 The drug and sterile water for mixing
 Gallipot with sterile cotton wool balls
 Receiver for used swabs
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  Sterile 2mls, 5mls, or 10mls syringes and needle free
 Alcohol impregnated swab
 Sharp bin
 Prescription chart
Procedure
1. Explain procedure to patient to gain consent
2. Check the medication chart to confirm that is if the dose is correct
3. Organize the equipment and send to bed side and provide privacy
4. Wash hands and put on gloves depending on the medication to be given
5. Prepare the medication if a vial or ampoule and calculate the right dosage to be
administered
6. Put the patient in a comfortable position
7. Expose the site of the injection
8. Clean the site with alcohol impregnated swab and allow to dry
9. Stretch the skin slightly with your non-dominant hand
10. Holding the syringe away from the site of the patient to prevent fear in them, tell the
patient you are about to inject then insert the needle slowly, swiftly and firmly at angle
of 900 to the skin. Leave 0.5- 1cm of the needle showing
11. Withdraw the plunger slightly to check the needle has not entered a blood vessel
12. Depress the plunger steadily not too quickly until the syringe is empty
13. Quickly and smoothly withdraw the needle from the skin and press firmly on the site
with the swab or tissue until any bleeding stops
14. Discard the needle into the sharp bin
15. Thank patient and make him comfortable in bed
16. Discard trolley and remove screen
17. Wash hands, indicate in the prescription chart that medication given and document all
findings in the nurse’s note.

Subcutaneous (SC) injections

SC injections are injected into the innermost layer of the skin called the subcutis or hypodermis
which is made up of a network of fat and collagen cells. These injections work more slowly
than IV or IM because the area does not have such a rich blood supply. This type of injection is
used to administer medications like insulin for diabetes, hormone injections for fertility
treatment and blood thinning agents to prevent clots. The sites for SC injections include
A. The lower abdomen (belly or stomach area) except for the 2inches (5cm) area around
the navel (belly bottom)
B. The front or outer sides of the thighs
C. The upper area of the buttock
D. The upper outer area of the arms (if being administered by someone else)

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Administering SC injection
Requirements
 Tray or receiver
 Syringe of appropriate sizes (0.5-2mls)
 Free needle of 25G
 Gauze/ cotton wool swabs
 Sharp bin
 Prescribed drug
 Prescription chart
Procedure
1. Explain procedure to patient
2. Check the drug against the prescription and check the patient’s name
3. Provide privacy and send items to bed side
4. Wash hands and prepare drug to be used in the right dosage
5. Select the site for the injection and clean with swab
6. Pinch up the skin using the thumb and first finger of your non-dominant hand and insert the
short needle into the subcutaneous tissue at an angle of 80-900
7. It is not necessary to withdraw the piston as it is unlikely that blood vessel will be
punctured
8. Inject the drug slowly, on completion pause briefly before withdrawing the needle as it
helps to prevent back tacking
9. Do not massage the site but rather use tissue to wipe away the blood
10. Dispose the needle into the sharp bin quickly
11. Thank patient and make him comfortable in bed
12. Discard tray and wash hands
13. Sign the prescription chart and document all findings in the nurse’s note
2. Intradermal (ID) injections
ID injections are given directly into the middle layer of the skin called the dermis. This type of
injection is absorbed more slowly again than IV, IM, SC. ID injections are commonly used for
allergy and TB testing. The common sites for an ID injection are
a. The inside or ventral aspect of the forearm
b. Upper back under the shoulder blade
NOTE:
1. When receiving SC and IM injections regularly it’s recommended to rotate the site of your
injections. Injecting in the same spot each time can cause the skin in that area to become
lumpy or sunken

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2. When giving SC injections the skin is not cleaned because repeated use of alcohol causes
the skin to harden which interferes with absorption.
3. Not more than 2mls should be given by SC route
4. Massaging the area of SC injections affects absorption of the drug

C. ABBREVIATIONS USED IN PRESCRIPTION

Abbreviation Latin Meaning
ac ante cibum before meals
bid bis in die twice a day
gt Gutta drop
h.s hora somni at bedtime
o.d oculus dexter right eye
o.s oculus sinister left eye
p.o per os by mouth
p.c post cibum after meals
p.r.n. pro re nata as needed
q.d quaque in die everyday
q.d. or q.i.d. quarter in die four times a day
t.d. or t.i.d. ter in die three times a day
a.d. Adde up to
ad lib ad libitum to the desired amount
ad sat ad saturandum to saturation
aq Aqua Water
aq dest. aqua destillata distilled water
b.d or b.i.d. bis in die twice daily
g. gram
inf. Infusum an infusion
mist. mistura. mixture
N. or noct. Nocte at night
p.r. per rectum by the rectum

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 p.v. per vaginam by the vagina
q.q.h. quartis horis four hourly
s.o.s si opus sit if necessary
fahr.(F) Fahrenheit
stat. Statim Immediately

D. DANGEROUS DRUGS ACT

Dangerous drugs also known as drugs of dependence (DDA) are prescription medicines that
have a recognized therapeutic need but also a higher potential for misuse, abuse, and
dependence. Administration of drugs of dependence in a health services facility includes
additional documentation requirements to other medications such as completing a register to
account for quantities used and discarded, details of the prescriber and patient and the persons
administering and witnessing the administration. Regular counting and record keeping of stock
(shift change and when supplies are received) is also undertaken as a reconciliation measure,
ensuring security of supplies is maintained. All drugs should be under lock and key and kept by
the nurse in charge.
Examples of such drugs include
1. Pethidine
2. Cocaine
3. Opium
4. Morphine.

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 CHAPTER 10
10 SKILLS TO MEET SUPPORTIVE NEEDS OF THE DYING
Dying is the one certain thing in life- we will all die. Some people unexpectedly as a result of
illness or accident and some gradually from a chronic illness die. The college of nursing
believes that no matter what the reason everyone the right has to be cared for with dignity and
respect as they approach the end of their lives.
The term end of life usually refers to the last year of life, although for some people this will be
significantly shorter. The term palliative care is often used interchangeably with end of life.
However palliative care largely relates to symptom management rather than actual end of life
care. Caring for the dying is not solely done by nurses but together with the patient’s family
and other health care workers and also members of the community.
The team include the nurse (one or more), the doctor or specialist, social worker, chaplain,
pharmacist, dietician, physical and occupational therapist, and other allied health workers.
The nurse’s responsibilities or task include
1. Assessing for pain and other distressing symptoms, providing evidence-based
interventions to alleviate them, and preventing initiation that may not improve comfort and
quality of life.
2. Nurses also work with team members to attend to the psychological and spiritual
dimensions of terminal illness.
3. Nurse should work with the family members as they also shift their focus from curing the
patient to palliative care. The commitment to family members should continue after the
patient’s death with support and referral for counselling if indicated.

LAST OFFICES
Last office is the final service offered as a mark of respect to the dead person before burial or
cremation.
The term last office relates to the care given to the body after death and is done to ensure the
body is treated with respect and practice is carried out with regard to the wishes expressed by
the patient before death and the wishes of their family following death.

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Symptoms Of a Dying Patient

 The nose is pinched and cold

 The skin is cold and clammy and covered with sweat
 The eyes are glazed and sunken and the lids half closed
 The face may become pale
 The mouth may sag open, the lips and tongue dry
 The pulse is weak and rapid, often imperceptible
 The breathing may be shallow and sighing or noisy and stertorous
 The patient is unable to support himself and sinks very low into the bed
 There is incontinence of urine and feces due to loss of muscle control

Care Of The Body After Death

The following should be done when the nurse realizes the patient is dying
1. Screen the bed
2. Ask the relatives to wait in the waiting room
3. Call the medical doctor on duty to come for certification of death
4. Note and record time vital organs ceased
5. Confirmation of death should be written in the nurses note
Once the death has been confirmed and the relatives have been ushered into the living room

 Remove all bed appliances and equipment used on the patient

 Lay the patient on his/her back with the assistance of two nurses and straighten the limbs
 Close the eyes and mouth if not closed, apply small wet piece of cotton wool swab place
over the eyelids to stabilize it and a bandage to support the jaw
 Cover the whole body with a sheet and leave for a while
 Inform the relatives if they wish to see the body for the last time before it is prepared and
sent to the morgue.
 Give emotional support to the bereaved family.

Preparation Of the Body

Requirements
They are place on trolley
o Gallipot containing cotton wool swab
o A receiver to collect urine
o A basin with warm water
o Washing flannels
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 o Soap and nail brush in a dish
o Two pair of dressing forceps
o Bandages
o Soiled linen receptacle
o Plaster and identification label
o Clean personal linen or mortuary gown and sheet
o Scissors

Steps
1. Prepare and send trolley to bed side and provide privacy
2. Turns body to lateral position with a receiver to collect oral secretion
3. Turns body to the supine position and applies gentle pressure over the lower abdomen to
empty the bladder into a receiver.
4. Ensures eyes are closed and cleans the body
5. Clean the nostrils and ears and mouth and replaces dentures if any and removes all tubes
6. Trims the nails, shave the males’ beard, and saves for the relatives
7. Remove all jewelry including wedding rings and beads, records and hand over items to
the next of kin or ward in charge
8. Redress wound if any secures dressings with a loss tape or bandage
9. Pack orifice- nostrils, ears, rectum, and vagina with cotton wool using forceps to prevent
leakage
10. Puts a label on the arm and the body with the following
a. Age
b. Sex
c. Ward
d. Diagnosis
e. Date and time of admission
f. Date and time of admission
g. Date and time of death
11. Wraps body in a sheet ensuring patient that the face and feet are covered, and all limbs
held securely in position
12. Make arrangement to transfer the body to the mortuary
13. Check property with a second nurse
 List of property in a value or property book, locks the property in a
safe place, hands them over to the next of kin if available and asks
this person to sign the book.
14. Clear away any equipment used and observes infection prevention protocol
15. Clear the bed locker and all appliances
16. Document in the admission and discharge book and daily ward state
17. Takes patients folder to the revenue office for assessment of hospital bill

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 18. The nurse should advise the relatives on what to do that is for them to come for the death
certificates and the need to register the death at the registry.

CHAPTER 11
11 GRIEF AND THE GRIEVING PROCESS
Grief is the natural response to a significant loss, particularly the loss of someone to which a
bond or affection was formed.
Although conventionally focused on the emotional response to loss, grief also have physical,
cognitive, behavioral, social, cultural and spiritual dimensions.
Grief can also be experienced as a result of loss of home, job, pet, etc. In short grief can appear
when we lose anything, we form a strong emotional connection with.

TYPES OF GRIEF
Anticipatory grief
Defined as grieving that occurs before the actual loss. As soon as you accept that someone you
love or cherish has a terminal disease and is going to die, grieving begins.
Anticipatory grief helps to reduce shock, confusion and depression as families are usually
prepared for the loss.
Also, for some, it allows for meaningful time to be spent with the individual leading to a sense
of closure and peace. People may also feel guilty thinking that grief equals giving up on
someone who is still alive.
Whiles some think anticipatory grief lessens the impact of the loss after the person passes
away, it does not always work that way.

Disenfranchised Grief
One’s grief is disenfranchised, when their culture or society make them feel their loss/grief is
insignificant, this complicates the grieving process because, it cannot be expressed openly, and
social support is mostly unavailable.

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Situations that can cause disenfranchised grief include
 When the relationship is not recognized/ stigmatized by others. Example, partner from
extra marital affair
 When the cause of death is stigmatized. Example, Suicide and drunk driving.
 When a loss is not acknowledged. Example, death of a pet
 When the griever is excluded. Example, very old adult, people with cognitive effect.

Complicated Grief
It refers to grief reactions and feeling of loss that are debilitating, long lasting and impairs your
ability to engage in daily activities.
Other types of grief such as Chronic Grief, Exaggerated Grief, Delayed Grief and Inhibited
Grief all fall under the bracket of complicated grief.

 Chronic Grief: Strong grief reactions that do not subside and last over a long period of
time. Continually experiencing extreme distress over the loss with no progress towards
getting better or improving function.

 Exaggerated Grief: an overwhelming intensification of normal grief reaction that

worsens overtime. Characterized by extreme and excessive grief reactions possibly
including nightmares, self-destructive behaviours, drug abuse, suicidal thoughts,
abnormal fears and the emergence of psychiatric disorders

 Delayed Grief or Postponed Grief: when grief symptoms and reactions are not
experienced until long after a person’s death or a much later time than its typical. The
griever consciously or unconsciously suppresses these reactions. For some people, this
means the feeling goes with time when they find it harder to cope than the initial after
mouth of the event.
Later, some people may experience an intense grief reaction triggered by a smaller loss

 Inhibited Grief: It appears when the griever avoids facing the realities of losing
something or someone and carries on as if nothing has happened. Such grievers turn
their energy and attention to someone or something that will keep them distracted and
tend to hide their feeling. Inhibited grief can lead to exhaustion and manifest itself in
physical symptoms like migraine

Collective Grief
Grief held by a collective group such as a community, village or nation. Usually as a result of
an event such as war, natural disaster or death of a public figure.
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Cumulative Grief
When one experiences another loss whiles still grieving. This is also referred to as “grief
overload”,

STAGES OF GRIEVING
1. Denial
The first stage of grieving.
Denial helps to minimize the overwhelming pain of loss. As we process the reality of our loss,
we are also trying to survive emotional pain. It can be hard for the individual to believe he or
she has lost an important person in their life, especially when they may have spoken with or
seen the deceased few minutes or days ago. At this stage life makes no sense and it takes time
to adjust to this new reality. People usually reflect on the moments and experiences they shared
with the person and how to look forward without them.

2. Anger
It is common to experience anger after the loss of a loved one. The griever is trying to adjust to
a new reality and is experiencing extreme emotional discomfort. This type of anger turns to be
socially accepted and underneath this anger is pain. This can leave the griever feeling isolated
and perceived as unapproachable by others in moments when they need comfort, connection
and reassurance. The truth is that, this anger has no limit it can extend not only to friends,
family, doctors, the deceased, the griever, objects but also to God. That is why a lot of people
ask questions like” where is God in this?”

3. Bargaining
It usually commences before the loss (Anticipatory grief). But can also occur after the loss.
Here, the griever is willing to do anything for the loved one to be spared. When bargaining
starts to take place, we are often directing our request to a higher power or something bigger
than we are that may be able to influence a different outcome. Bargaining can come in a
variety of promises such as;
“God, if you heal this person, I will turn my life around”
“I will never abuse my wife again if you let her live”
“I will give all my property to the orphanage if you give me a second chance”
Guilt is often bargaining’s companion. While bargaining, we look back at our interactions with
the person we are losing/ have lost and note all the times we could have made things right.
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4. Depression
During the grieving process, there comes a time when our imaginations calm down and we
slowly start to look at the reality of our present situation. Bargaining no longer feels like an
option and we are faced with what is happening. We start to feel the loss of our loved one more
abundantly and grief enters our lives on a deeper level. The emotional fog begins to clear, and
the loss feels more present and unavoidable. In this moment, we turn to pull inward as sadness
grows. We might find ourselves retreating, being less sociable and reaching out less to others
about what we are going through. Although this is a very natural stage of grief dealing with
depression after the loss of the loved one can be extremely difficult.

5. Acceptance
It is often confused with the notion of being alright or okay. When we come to a place of
acceptance it is not that we no longer feel the pain or loss however, we are no longer resisting
the reality of our situation and we are not struggling to change it. We accept that it is a new
norm with which we must learn to live.

Common signs and symptoms of grieving

 Fatigue
 A hollow feeling in your stomach
 Dry mouth
 Changes in appetite
 Insomnia
 Deep sighing
 Palpitation
 Shock
 Difficulty in Concentration
 Helplessness
 Isolation
 Impatience
 Anger
 Fear
 Apathy
 Relief

Grief is a universal emotion, but the experiences are not. There is no normal amount of time to
grieve. Each person’s grieving process is unique and depends on several factors such as

 Personality
 Beliefs
 Support network
 Type of loss
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What to do to help the griever
 Avoid rescuing of fixing
Remember the person grieving does not need to be fixed, it is normal. In an attempt to be
helpful, we may offer uplifting, hopeful comments or even humor to try to ease their pain.
Although the intention is good, this approach can leave people feeling their pain is not seen or
valid.

 Make yourself accessible

Offer space for people to grieve but let them know you are available when they are ready.
Engage them in conversations, help them recall good times and help put regrets into
perspective.

 Encourage them to take care of their health

Encourage good nutrition, adequate rest and sleep, maintain personal hygiene etc.

 Be patient
We may want to help badly and make the griever feel better but remember grief takes time and
varies between individuals. Avoid saying things like “You should be getting on with your life”.

 Make referrals if necessary

Support groups, faith communities, Psychologist, Counsellors, etc.

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