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CONTENTS
Abbreviation ............................................................................................. 5
Preface ................................................................................................. 6
Chapter 1. The organization of the nurse's work. Medical
documentation, the order of filling in and keeping the
documentation by the nurse ..................................................................... 7
1.1.
The features of deontology in the nurse's work with
children and their relatives ............................................................... 7
1.2. ............................................................................................................... T
he structure and functions of the children's hospital ........................ 9
1.3. ............................................................................................................... B
asic functional duties of the nurse in the children's hospital .......... 11
1.4.
Medical documentation.The rules and ways of filling in
and keeping the documentation by the nurse ................................ 12
1.5. ............................................................................................................... T
he keeping and calculation of drugs ............................................... 12
Chapter 2. Duties and actions of the manipulation nurse
at the paediatrics department .............................................................. 15
2.1. ............................................................................................................... A
dmission and registration of the patients in the hospital reception 15
2.2.Measurement and recording of patient's vital signs
(body temperature, pulse rate, respiration, blood pressure) ........... 18
2.3.
The ............................................. oral administration of drugs
32
2.4.
The
anthropometrical measurement in children
of different ages ............................................................................. 33
2.5.Medical care in fever ................................................................ 36
Chapter 3. Providing of medical and diagnostic process
in children's hospital ............................................................................... 39
3.1.Stool specimen collection for testing. Preparation of patients and
necessary equipment for taking feces for ova and parasites, fecal
occult blood test, hematest reagent tablet test, enterobiasis tape test
39
3.2.
Collection of urine for Zimnitskiy, Nechiporenko tests,
Addis sediment count. Chemical examination of urine.
Urine culture.........: ........................................................................ 42
3.3. ............................................................................................................... C
ollection of a nose and throat swab ................................................ 46
3.4. ............................................................................................................... B
asic types of enemas. Enema administration .................................. 48
3.5.
Technique
of application of mustard plasters.
Application
of a hot and cold compresses ........................................................ 53
3.6. ............................................................................................................... T
echnique of gastric lavage .............................................................. 58
3
3.7. ............................................................................................................... I
nserting the flatus tube .................................................................. 59
Chapter 4. The basic duties of a nurse of manipulation room
in children's department ...................................................................... 61
4.1. ........................................................................................................................ T
he basic duties of a nurse of manipulation room .................................... 61
4.2. Introduction of medicinal agents into children ................................. 62
4.3. Drug dosage calculation and administration .................................... 77
4.4. ........................................................................................................................ T
he technique of performing intravenous infusions............... 794.5. Medical
instrument disinfection and sterilization ................................................ 82
Chapter 5. Duties of the nurse on providing the personal
hygiene for children of different age .................................................... 86
5.1. ............................................................................................................... S
pecial rules of hygiene of children of the first year of life. Intimate
washing of girls. Types of baths ..................................................... 86
5.2. ............................................................................................................... T
he technique of oral hygiene, eye, ear and nose care ..................... 90
5.3. ............................................................................................................... C
lamping, cutting and care of the umbilical cord ............................. 92
5.4. ............................................................................................................... G
iving eye, ear and nose drops ......................................................... 93
5.5.Rules of using pocket and permanent inhalers ......................... 95
5.6. ............................................................................................................... O
xygen therapy................................................................................. 98
Chapter 6. Duties of the nurse on providing the feeding
of children of the first year of life ....................................................... 106
6.1 .The technique of breast feeding ............................................ 106
6.2.
The technique of feeding of children from a bottle
in artificial feeding ..................................... ................................. 109
6.3. .......................................................................................... A tube
feeding ............................................................................ ........... 110
Bibliography ............................................................................. . ........... 118
Appendix .............................................................................................. 119
Index .................................................................................................... 121
4
ABBREVIATIONS
b.p.m.
- beats per minute
BBP
- blood borne pathogen
BM
- bowel movement
BP
- blood pressure
BSA
-body surface area
BVM
- bag-valve mask
cc
- cubic centimeter
CPAP
- Continuous Positive Airway Pressure
DAP
- diastolic arterial pressure
Gl
-gastrointestinal
HIV
- human immunodeficiency virus
IM
- intramuscular
IV
- intravenously
IL
- liter
NG
- nasogastric
OG
- orogastric
PR
- pulse rate
RBC
- red blood cells
ROP
- retinopathy of prematurity
RR
- respiratory rate
SAP
- systolic arterial pressure
SubQ
-subcutaneous
tsp
- teaspoon
UNICEF
- United Nations International Children's Emergency
Fund
UTI
- urinary tract infection
WBC
-white blood cells
WHO
-World Health Organization
PREFACE
This manual corresponds to the syllabus in practical training of nurses
for higher medical establishments of the 3rd- 4th levels of accreditation
specializing in "Pediatrics".
The manual deals with the basic principles and the organization of the
work of a nurse at the pediatric department, expounds aspects of providing
the medical and diagnostic processes at a children's inpatient department,
describes the basic items of the personal hygiene of children at different
ages and the feeding of infants during the first year of their life.
5
The materials of the manual are accompanied by a sufficient number
of illustrations, which demonstrate a sequence of making medical
manipulations. The technique of taking anthropometric measurements at
different periods of the child's life, BP, pulse, respiration rate, thermometry,
the technique of breastfeeding of infants during the first year of their life
are described in detail. Each section ends with a list of questions for the
consolidation of the material studied.
The authors hope that this manual will contribute to raise the level of
training of third-year students and their mastering of practical skills in
compliance with the syllabus in the subject of "Nursing".
CHAPTER 1.
THE ORGANIZATION OF THE NURSE'S WORK.
MEDICAL DOCUMENTATION, THE ORDER OF FILLING IN AND KEEPING THE
DOCUMENTATION BY THE NURSE
1.1. The features of deontology in the nurse's work
with children and their relatives
"Deontology" is a Greek origin derivative from words: deon -obligation
and logos -science. The science of the duties and rights of the doctor and
medical staff in relation to their patient is called deontology. Deontology
may also be defined as a set of rules and principles of medical ethics.
"Deontological ethics" means the theories that place special emphasis on
the relationship between the duty and morality of human actions. In
deontological ethics, an action is considered morally good because of some
characteristic of the action itself, but not because the product of the action
is good. Deontological ethics states that at least some acts are morally
obligatory regardless of their consequences for human welfare.
The concepts of morals and professional duties of practitioners have
changed during centuries, depending on the social, economic and class
relationships, the political structure of the state, the level of civilization,
national culture, religious traditions, and many other factors.
The Greek medical schools greatly contributed to the development of
the deontology. Hippocrates is a Greek physician of antiquity who is
traditionally regarded as the father of medicine. The Oath is the ethical code
attributed to the ancient physician Hippocrates, adopted as a guide to
conduct by the medical profession throughout the ages and still used in the
graduation ceremonies of many medical schools. The core of medicine and,
consequently, of the Hip- pocratic ethics is reflected in the paragraph of the
Oath, that states:
I will apply dietetic measures for the benefit of the sick according to my
ability and judgment; I will keep them from harm and injustice.
"For the benefit of the sick" - with these six words the overall meaning
and end of medical practice as a healing relationship is disclosed; this is
6
what medicine is for: the benefit of the sick. Good of benefiting the sick is
the core of the Hippocratic ethics.
An indispensable part of medical ethics consists in the behaviour of a
medical staff in some particular situations (both at work and outside the
hospital).
Not only the level of the professional knowledge and skills determines
the effectiveness of the treatment and caring for the sick. Moral qualities of
the medical personnel are very important in their work too.
Any illness, especially a chronic one, a critical state of a patient's health
may cause a serious psychological trauma which leads not only to a worse
physical state but also to severe disorders in the psychoemotional state. All
patients' thoughts are concentrated on the process of receiving an effective
help as soon as possible. To gain a patient's confidence is a great progress
on his way to the quickest recovery.
That is why the medical worker should possess not only such a quality
as a high professionalism but also be decent, kind and responsive. "Love
and care are the best medicine"- Paratsels wrote. The successful therapy
greatly depends on the authority of the doctor. This authority is won not
only by his own labour but also by profound knowledge, because an
authoritative physician is always a competent physician.
The doctor must gain the patient's confidence, show his sympathy for
the patient. Ask your patient about his complaints, about the beginning and
development of the disease, so that patient might feel confidence in his
doctor and tell him not only his main complaints but intimate details that
must be important for making diagnosis and administering treatment
correctly.The doctor must be able to improve the patient's spirit by giving
him hope for recovery.
However, having established confiding relations with your patient,
never demonstrate your confusion or helplessness. On the contrary, you
should be able to reject strictly and firmly any unnecessary demands of your
patient (to persuade him in the inexpediency of these demands).
The appearance of the medical staff is also of great importance, and it
is quite natural that any dirty gown, hands, nails, careless clothes and hairdo
are unacceptable for medical workers.
Speech also plays an important part in the process of a patient's
treatment - a wrong word addressed to the sick with psychic disorders may
do a lot of harm.
This is the reason why no discussions of any illness progress,
unfavourable complications or examination results are acceptable in the
patient's presence. One should not express regret about the fact that the
sick consulted a doctor too late, that the illness was neglected and is
difficult to cure at present, or"comfort" the patient by saying that the
present state of medicine does not have enough possibilities to treat him in
the way he heeds. Do not tell the patient's relatives about an unfavorable
outcome of his illness at his bedside even if he is unconscious. You should
7
take into consideration that there are other patients in the same ward with
the same diagnoses who may be very sensitive to any negative information.
It is necessary to realize that ill (especially seriously ill) people "catch" every
word said by the medical staff, that is why you should talk in a calm and
restrained way and see that unfavorable results of examinations and case
reports with diagnoses of serious (sometimes fatal) diseases were not seen
by your patients; do not discuss the possible outcomes of these
patients'illnesses
in other wards either.
At the hospital, the doctors and nurses spend most of their time with
patients. The patients confide their secrets to them. It is written in the
Hippocratic Oath: "What I may see or hear in the course of the treatment or
even outside of the treatment in regard to the life of men, which on no
account one must spread abroad, I will keep to myself, holding such things
shameful to be spoken about". "Keeping secrets" is a medical professional
duty. Everything the physician knows about his patient should be kept
secret; otherwise the patient will suffer moral and sometimes material loss.
This, however, does not hold for cases where keeping a secret may do
harm to other people. For example, if the disease is infectious, the patient
should be hospitalized because his isolation arrests the spreading of the
disease and provides better conditions for treatment. People close to the
patient should sometimes be informed of the disease so that they must
strictly follow sanitary rules and that any new cases, if they are revealed,
must be treated in due time. The diseases caused by negative interrelation
of the medical staff and patient are called iatrogenic ones.
The aspects of deontology in the practice of medical workers with
children and their families are still one of the most relevant problems in
pediatrics at present time. At hospital, children are cared not only by the
medical staff (doctors, nurses), but also by the children's relatives. The
duration of the contact of the medical personnel with the sick child and his
relatives may differ. Sometimes the contact can last several weeks and even
months. The adhering to ethical-deon- tological principles in personal
contacts between the personnel and between the personnel and sick
children and their relatives influences not only the trust of the children and
their family towards the medical staff, but also, in many cases, the success
in treating and rehabilitating sick children.
1.2. The structure and functions of children's hospital
The state system of medical aid to children, that exists in our country,
includes different types of children's treatment-and-prophylactic
establishments,
which
include:
outpatient's
clinics,
hospitals,
Youth-Friendly hospitals, sana- toriums and health centers, clinics of
research institutes, dispensaries, etc. The knowledge of the specific
character of the work and functions of each medical establishment is
necessary for future family doctors and pediatricians.
8
A children's hospital is a treatment-and-prophylactic establishment
for children under 18 who need constant medical observation, intensive
therapy or specialized aid. The role of the children's hospital in the system
of treatment- and-prophylactic establishments is peculiar, as it is here
where bad patients are hospitalized to, the modern diagnostic equipment is
concentrated, and its staff includes highly skilled doctors and nurses.
Particular attention in the activity of the children's hospital is paid to
maintaining order and cleanliness, as well as to the continuity in the work of
its staff. The junior, paramedical and medical staff must observe rules of the
sanitary and antiepidemic regimen. Particular attention should be paid to
preventing hospital-acquired (nosocomial) infections. In order to ensure
sanitary-epidemic well-being at the children's hospital, it is necessary to
follow the existing sanitary rules: to observe the principle of isolation of
certain children's groups when admitting patients to the departments (units,
isolation wards, etc.), to use the available premises according to their
intended functions, to create the optimum air-heat flow in the premises, to
stick to rules of work for the food unit, canteens and food distribution
rooms, to follow rules for giving employment to the staff and ensure
opportune obligatory preventive medical examinations, to follow rules of
personal hygiene by children and staff, to have means for carrying out
disinfecting measures (sufficient amounts of the uniform, equipment for
doing the premises, as well as washing and disinfecting means).
The children hospital can have general departments (it means - not
specialized) and specialized departments. The development of specific
treatment caused the creation of specialized departments - such as
surgical, neonatal, cardiological, gastroenterological, allergological,
nephrological, hematological, endocrinological and intensive care
departments.
The main diagnostic and treatment measures are realized in hospitals.
Children are admitted to the hospital according to the district pediatrician's
referral to treatment, or the ambulance doctor decision. The admission of
the child to the hospital is the cause of severe psychogenic trauma due to
the separation the child from parents. It is necessary to take into
consideration when we decide to admit a child to the hospital. It is necessary
to understand when we organize the hospital environment. The best idea is
to admit the child together with his mother.
It is necessary to take into consideration that almost all cases of acute
children diseases have the infectious origin, so patients suffering from this
diseases, need to be isolated from other children. It can be done if the department has box or semi-box system.
The structure of the children's department:
- a reception ward (examination and isolation boxes, a sanitary
entrance box, a doctors' cabinet, sanitary wards);
- treatment wards (wards, a nursing post, a manipulation room,
medical rehabilitation cabinets, a bead of the department cabinet, a doctors'
9
lounge, a canteen, a medical staff room, a room of the senior nurse, sanitary
wards, a game room or an educational room);
- laboratory;
- intensive care unit.
- a diagnostics department, auxiliary wards (a kitchen, a drug store, a
medical statistics cabinet, an archival depository;
- an administrative setting.
The volume of work of a children's hospital is determined by its type.
N.B. a nursing post for the convenience of constant supervision is
often located in corridors of the department; near the table of the nurse
there are some hospital shelves in which the most necessary medicines and
medical tools are kept;
The main functions of the children's hospital are as follows:
- Providing highly qualified medical aid.
- Implementation of up-to-date methods of diagnostics, treatment,
and prophylaxis into practice.
- Consultative work.
At the present time, a three-staged system of ill children's service is in
practice (doctor nurse-►junior nurse).
1.3. Basic functional duties of the nurse in the children's department
The basic duties of the nurse on duty:
1. Execution of the doctor's prescriptions in accordance with their list.
2. Exercising of sanitary state control in the wards under
responsibility.
3. To control how the patients carry out hygienic measures; to be
responsible for a change of the patients' clothes and bedclothes.
4. Material sampling for laboratory researches and exercising control
over getting the results back.
5. Getting the necessary instruments and equipment ready for work.
6. Examining skin and scalp of the children admitted to the
department, sending them in appropriate wards, and getting them know
the rules of staying in the hospital.
7. Taking the patients'temperature, checking the pulse and
respiratory rate, measure diurnal urine discharge and register the data in
the temperature chart (see Appendix 2), carry out an anthropometry of the
patients.
8. Prepare the sick for different examinations and transport them to
diagnostic rooms.
9. Take care of the proper medical feeding of the sick (dietetic
therapy), check the food quality.
Every morning all the medical personnel gathers in the staff lounge:
the persons who were on duty the previous night and those who must be on
duty during the new day. The nurse on duty is not allowed to leave her post
10
in any case without delegating her duties to the next nurse on duty. The
nurse on duty must turn over her duty to another nurse on duty. The nurse
who changes the previous one and the nurse who finished her duty should
check the sanitary condition of the department. The nurse who turns over
her duty reports about the patients' conditions, the doctors' prescriptions
which she performed and about those prescriptions which need to be
performed, the number of the admitted and discharged patients.
Possible reasons of deterioration in the condition of other children (a
rise in their body temperature, problems with defecation, etc.) and the
maximum help rendered to them are described.
Then the nurse on duty reports about all the patients who have some
increase in temperature, or whose condition became worse, gives the list of
those who did not hand over some analysis with the indication of the
reason, possible
peculiarities of giving and taking medicines.
1.4. Medical documentation. The rules and ways of filling in and keeping
the documentation by the nurse
It is impossible to overemphasize the importance of keeping exact
records of all treatments and medications as well as a record of the patient's
behavior. The medical card is a written and legal evidence of his treatment
during the hospital stay or of occurrences at home. The card reflects facts
only and not judgments. Careful and accurate documentation is vital for the
patient's welfare.
Careful documentation is perhaps the most important thing you can do to
protect yourself against a lawsuit. If a treatment or medication was not
documental legally, the procedure is not considered to have been done or the
medication have been given.
There are uniform letterheads of medical documentation for prophylactic and treatment establishment activity control. The work with children
of corresponding district and in children's prophylactic-and-treatment
establishments is fixed in such a documentation. Taking into account the
fact that the pediatrician is the main organizer of this activity and of the
medical aid provided to children under 18 years old, one must know this
documentation.
The Main Documentation of the Children's Department:
1. Medical card (registration form No.003).
2. An abstract from the hospital patient's medical card (No. 027).
3. The register of patient's transfer.
4. The list of doctor's prescriptions.
5. The list of temperature chart.
6. The register for pediculosis and scabies examination.
7. The register of infectious patients.
11
A hospital patient's medical card (case history) is the main initial
medical document filled in for each patient of the in-patient department. It
is a legal document; the term of its keeping is 25 years.
There is also a special register which shows the patients'transfer (the
duty of the medical personnel is to write the information into it).
1.5. The keeping and calculation of drugs
There is also the order of drugs admission to a department:
- a doctor writes down the prescription to the prescription list;
- a nurse composes demands for necessary medicinal agents and
hands them to the senior nurse every day;
- on this basis the senior nurse composes a special demand signed
by the chief of the department and sends it to a drug store. It should be
borne in mind that narcotics, poisons, and spirit are prescribed on separate
demands.
The drug store hands the necessary medicinal agents on the basis of
these demands.
The senior nurse checks the correspondence of the obtained medicinal
agents to the demand, the presence of labels, and their correspondence to
the agents'titles and dosage. The term of validity must be checked
thoroughly. If the nurse has any doubts as for agents or their term of
realization, the drugs are returned to the drug store. The drugs suitable for
use are given by the senior nurse to the nurse on duty's post.
Liquid medicines (mixtures), decoctions, vaccines, and eye drops
cannot be preserved for a long period of time; that is why they are to be kept
in a fridge. Other drugs are preserved in special cupboards, which are
marked and closed. There are separate shelves for agents, which are
introduced intravenously, for external application, sterilized solutions,
smelly substances, inflammable substances (spirit, etc.), and bandaging
materials.
Drugs are to be kept in corresponding vessels: infusions and mixtures
in jars of one liter and half a liter capacity, drops - in small bottles,
ointments - in small jars; drugs, which are destroyed in the sunlight (iodine,
bromine) are to be kept in dark vessels.
The nurse cannot change drug package herself, pour drugs from one
vessel to another. It is strictly prohibited to tear the label off, cross any
writings, stick nonstandard labels, put different pills and powders into one
pack. It is necessary to keep an eye on drugs term of validity.
Mixtures, infusion, decoctions, mucilage, and eye drops are to be
preserved for not more than 2 days. The term of validity of sterilized
solutions and emulsions is 3 days, of other drugs -10 days. The term of
validity of industrial drugs is 2-5 years. All liquid forms of medicinal agents,
protein agents included serums, insulin, some antibiotics, ointments are to
be kept in the fridge at +2-10°C.
12
Small safes are used for storage of poisonous and strong medicines.
Poisonous and narcotic medicinal agents are kept in a safe labeled with "A"
letter (narcotics, atropine), and strong medicines (adrenalin, caffeine) - in a
safe labeled with "B" letter.
The list of preserved agents, single and daily doses for different age
and antidote (antipoisoned) scale are set on the inner side of the safe's door.
The quantity of poisonous and narcotic agents must not exceed 5 days; the
quantity of strong medicines must not exceed 10 days.
The senior nurse keeps the safe's key and the book of "A" and "B" agent
groups calculation. The senior nurse conducts drugs calculation; she has the
notebook of medicinal agents calculation signed by the head doctor. The
book of narcotic, poisonous, and strong medicines calculation is conducted
separately. This book is to be strung together, numbered, signed by the
head doctor, and contains an official stamp.The senior nurse conducts
calculation of narcotics used, puts in the number of the case history, the
patient's name, and the quantity of drugs used.
Tests for self-training
Q1. What does the three-staged system of ill children's service mean?
A. Doctor, nurse, junior nurse.
B. Doctor, nurse, senior nurse.
C. Head doctor, doctor, junior nurse. Q2. Medical deontology is:
A. The study of the professional duty of medical workers (doctors,
nurses, etc.) in relation to sick and healthy children, and people in general.
B.The study of anatomical and physiological features of a child at
different
ages.
C. The science of the duties and rights of the doctor and medical staff
in relation to their patient.
Q3. A children's hospital gives medical aid to children at the age:
A. From childbirth to 18 years.
B. From childbirth to 15 years.
C. From 1 week to 18 years.
D. From childbirth to 16years.
E. From 1 month to 18 years.
Q4. The first necessary step of activity of sanitary treatment is:
A. Inspection for pediculosis.
B. Clipping hair and nails.
C. Having a bath.
D. Rubbing with ethyl alcohol.
E. Wiping down skin with a disinfecting solution.
Q5. When communicating with a patient who cannot speak or understand English:
A. Insist the patient learn English.
B. Speak to the patient using appropriate medical terminology.
C. Learn some basic phrases in the patient's native language.
D. Write down instructions for the patient.
13
tion?
Q6. Which of the following is an example of the positive communica-
A. Ask a patient to repeat your instructions.
B. Interrupt a patient when he/she does not understand.
C.Treat all the patients in the same way.
D. Inform patients when you cannot spend any more time with them.
Q7. Change of linen in hospital should be done:
A. Twice a month.
C. Not less than 1 time per 7-10 days.
B. Daily.
D. Every other day. Q8. The basic
obligations of the nurse on duty are:
A. Cleaning the wards, halls and places of general use.
B. Changing the bed sheets and clothing of the patients.
C. Execution of the doctor's prescriptions in accordance with their list.
D.Taking care of the sanitary conditions of the furniture in the wards.
Q9. The medicinal agents of A group should be kept:
A. In a cupboard of a nurse on duty.
B. In a safe of a senior nurse.
C. In a staffroom cupboard.
D. In a chief of the department's cupboard.
E. In a refrigerator.
Q10. Information about the patient's intolerance to particular
medications is to be made:
On the title page of the case record.
In the temperature chart.
On the treatment sheet.
On the hospital's discharged patient list.
On the sheet of the emergency notification.
Key answers: Q1-A; Q2 -C; Q3 -E; Q4- A; Q5 -C; Q6- A; Q7 -C; Q8 -B;
Q9- A; Q10 -A
CHAPTER 2.
DUTIES AND ACTIONS OF THE NURSE AT THE PAEDIATRICS DEPARTMENT
2.1. Admission and registration of the patients in the hospital reception
Certain routines necessary to admit the patient are usually carried out
in the hospital reception. Before the patient arrives, the nurse should check
to be sure that the unit is completely equipped.
The patient is admitted either according to the planned order (planned
hospitalization - from out-patient department) or brought to hospital by an
ambulance (urgent hospitalization).
A sick person is admitted to hospital through the admissions
department where admitting, registration, examination, sanitary treatment
and transportation of patients are performed.
14
In the hospital reception the nurse records the title page of a medical
card, which include such information as full name, age, permanent address,
drug intolerance, etc. (see Appendix 1); records the information about the
sick down in the hospital admission register; records the information about
the sick down in the alphabetical register (surname, first name, date of
birth, date of admission, department, etc).
If the sick was unconscious while being admitted to hospital the
information about him is received from his relatives or people
accompanying him.
At the lack of documents the information about the unconscious sick
is registered with the description of his appearance and this information is
sent to the police immediately.
If the sick is in a grave condition a complete emergency medical aid is
provided in a treatment procedures room of the admitting office. In the case
of admitting the sick under 18 without any people accompanying him (a
casualty)
a
nurse
has
to
inform
his
relatives.
After registration the sick is referred to medical examination room
where a doctor examines him and identifies diagnosis. If there are some
difficulties to identify diagnosis the patient is isolated and consultations
with specialists are held.
If the sick has a referral to be hospitalized (according to the planned
procedure from the out -patient department) the diagnosis of his illness
identified by the doctor referring him is put down on the title page.
If no symptoms of an illness are identified the sick is let home. This
fact is written down in the register of hospitalization rejection. In some
cases (if they suspect an infectious disease), according to the doctor's
prescription a nurse takes a smear from the pharynx or nose.
The patient is examined to discover pediculosis and scabies. If the
doctor discovers pediculosis he carries out special disinfection.
Pediculosis is infestation by lice on the head, body, or pubic area.
Infestation is widespread in facilities that are overcrowded or inadequate for
personal hygiene or clean clothing. P. humanus capitis is transmitted by
personal contact and by such objects as combs and hats. There are three
stages in the life cycle of lice: the nit, the nymph, and the adult louse.
Nits are lice eggs (Fig. 1). They are hard to see and are often confused
with dandruff or hair spray droplets. Nits are found firmly attached to the
hair shaft. They are oval and usually yellow to white. Nits take about a week
to hatch.
Nymphs are baby lice. The nit hatches into a nymph. It looks like an
adult head louse, but is smaller. Nymphs mature into adults about 7 days
after hatching. To live, the nymph must feed on blood.
The adult louse is about the size of a sesame seed, has 6 legs, and is
tan to greyish-white (Fig. 2). In persons with dark hair, the adult louse looks
darker. Females lay nits; they are usually larger than males. Adult lice can
live up to 30 days on a person's head. To live, adult lice need to feed on
blood. If the louse falls off a person, it dies within 2 days.
15
Although localized predominantly on the scalp behind the ears and
near the neckline at the back of the neck, P. pubis sometimes involves the
eyebrows, eyelashes, and beard. Head lice hold on to hair with hook-like
claws that are found at the end of each of their six legs.
Fig. I.Nits on hair
Fig. 2. The adult louse
Pruritus is severe, and excoriation of the scalp, sometimes with
secondary bacterial infection, may occur. Small, ovoid, grayish white nits
(ova) are seen fixed to the hair shafts, sometimes in great numbers. Unlike
scales, they cannot be dislodged; they mature into lice in 3 to 14 days.
Prevention of pediculosis and reinfestation includes teaching children
and others to practice good hygiene and to avoid sharing combs, brushes,
caps, scarves, and clothing. For effective elimination of head lice, the
infested individual, family members that are also infested, and the home
must all be treated.
Treatment for lice involves using a shampoo, cream rinse, or lotion
that contains a medicine that kills lice. Such medicines are known as
pediculicides.
Permethrin cream 5 % is currently the treatment of choice. For
pediculosis, it should be left in place for 6 to 12 h before being washed off.
Nits and lice can be mechanically removed with a comb in most cases.
Para plus aerosol (exposure time -10 min). Introduction of aerosol is
con- traindicated in children aged up to 2.5 years.
Pedilin-emulthion, Nix (permethrin 3 % shampoo and 1 % cream); Itax
(phenothrin lotion or aerosol 3 % and 0,3 % shampoo); Nittifor lotion 50-60ml, (exposure time - 10min); Nok cream-shampoo (permethrin 1
%);Benzylbenzo- ate10 or 20 % ointment; Bubil-shampoo (pirethrin 180 mg
and acetic acid 600 mg); Spray-pax (pediculosis pubis extr. piretpum 160
mg and piperonyl butox- ide 320 mg). Sources of infestation (eg, combs,
hats, clothing, bedding) should be decontaminated by vacuuming, thorough
laundering and steam pressing, or dry cleaning. Recurrence is common.
Scabies (The Itch) is a transmissible ectoparasite infection, characterized by
superficial burrows, intense pruritus, and secondary infection. Scabies is
caused by the mite Sarcoptes scabiei and is transmitted by close contact with
someone affected. Mites are small eight-legged parasites (Fig. 3). Beginning
30 to 40 days after the infestation is acquired. Although the patient may
have hundred of itching papules, often there are aboutIO burrows.
The burrow is a fine, wavy, and slightly; scaly line a few millimeters to 1 cm
long. A tiny mite (0.3 to 0.4 mm) is often visible at one end of the burrow.
Burrows occur predominantly on the interdigital spaces, wrist flexures
surfaces and anterior axillary folds, about the areolae of the breasts in
females and on the genitals in males, along the belt line, and on the
buttocks.
Fig. 3. Scabies mite and rash
Treatment with topical medications is usually effective, and the
medication must be applied all over the body except the scalp and face. It
should be left on for up to 24 hours and then washed off the following day.
If hands are washed during that time, the treatment should be applied again
to the hands. All family members in close contact with the person with
scabies should be treated at the same time.
The topical medication of choice is 5%permethrin cream because it is
safe for all age groups. All skin-to-skin contacts (e.g, social contacts, all
family members) should be treated at the same time. We can use also:
Spregal- aerosol (esdepallethrine 63 mg and piperonyl butoxide 504 mg);
Nix (permethrin 1 % cream); Itax (Phenothrin lotion or aerosol 3
%);Benzylbenzoate10 or 20 % ointment; Bubil shampoo (Pirethrin 180 mg
and acetic acid 600 mg).
All patients are examined every 7-10 days for possible detection of
pediculosis and scabies. Treatment destroys both eggs and the active forms
of the mites; however, ovacidal activity has not been fully substantiated for
all available agents. Repeating the treatment 7-10 days after the initial
therapy will kill any newly hatched mites.
The information about detection of pediculosis or scabies, sanitary
treatment is recorded on the title page of medical card (see Appendix 1).
Seriously ill patients are taken to the department without sanitary
treatment. Corresponding information should be sent to the
sanitary-and-epidemiologic institution; the clothes are disinfected. If the
patient's condition is very serious hair is completely shaven off and burnt.
In addition, the affected child and parents need emotional support,
reassurance and vigorous instruction.
2.2. Measurement and recording of patient's vital signs (body temperature,
pulse rate, respiration, blood pressure)
Body temperature, pulse, respiration, and blood pressure (BP) are
important data collected by nurses. By using these data, assessments can
reflect changes in the patient's condition. Respiration and BP are called vital
signs or cardinal symptoms because these measurements are indicators of
vital functions that are necessary to sustain life.
Temperature, pulse, and respiration are usually observed together. It
has been the practice in many acute care hospitals to require this
observation at least morning and evening as a routine procedure for every
patient. In some illnesses it is important to make more frequent
observations of the cardinal signs. Changes in one of these signs may affect
the others, which is one of the reasons for observing them at the same time.
The physician will order the frequency for obtaining vital signs. The nurse,
however, also may use nursing judgment in obtaining vital signs.
Elevated temperatures are characterized as follows: temperature from
37 to 38 °C is called subfebrile, from 38 to 39° С -moderately high, from 39 to
40°C - high, arid over 40° С -very high. Temperature over 41 and 42 °C is
called hyper- pyretic and is dangerous to the patient's life.
Not only elevated temperature itself but also its circadian variations are
very important for diagnosing the diseases. Variations of temperature during
the day determine the type of fever. The following main six types of fever are
differentiated.
1. Continued fever (febris continua). The circadian variation does not
exceed 1°C. It is observed in patients with acute lobar pneumonia or II stage
typhoid fever.
2. Remittent fever (febris remittens). The circadian variations exceed ГС,
the morning lowesttemperature being over 37°C; it often occurs in
tuberculosis, III stage typhoid fever, purulent diseases, and lobular
pneumonia.
3. Intermittent fever (febris intermittens). The daily variations exceed
1°C, with complete apyrexia in remissions.
4. Hectic fever (febris hectica). The temperature rises sharply (by 2-4°C)
and drops to normal and subnormal level. The fever is often accompanied by
excessive sweating. It usually occurs in grave pulmonary tuberculosis,
suppuration, and sepsis. Inverse fever (typhus inversus). The morning
temperature is higher than in the evening; it sometimes occurs is sepsis,
tuberculosis, and brucellosis.
5. Irregular fever (febris irregularis). Circadian variations are varied and
irregular. It often occurs in rheumatism, endocarditis, sepsis, tuberculosis,
etc. According to the temperature curve recurrent (relapsing) and undulant
(Malta) fevers are distinguished. Recurrent fever (febris recurrens) is
characterized by alternation of fever and afebrile periods; it occurs in
relapsing fever.
6. Undulant fever (febris undulans) is characterized by periodic elevation
of temperature followed by its drop; it often occurs in brucellosis and
lymphogranulomatosis. The course of fever is characterized by a period of
elevation of temperature (stadium increment!), which is followed by the period
of high temperature and ending with the period of decreasing temperature
(stadium decrement!).
The temperature may decrease gradually during several days. This
termination of fever is called lysis. A sudden temperature drop (to norm
within 24 h) is called crisis. During abatement of fever in some diseases (e.g.
in typhoid fever), the daily variation of temperature exceeds 1°C. Regular
alternation of fever attacks (chills, heat, temperature drop with sweating) and
afebrile periods is characteristic of malaria. Attacks may occur every day,
every other day or every third day. The temperature rise may be only
transient, for few hours (one-day fever). It occurs in mild infection, excess
exposure to the sun, after blood transfusion, sometimes after intravenous
21
injections of medicinal preparations. Fever lasting up to 15 days is called
acute, and over 45 days - chronic.
Assessing Body Temperature
Body temperature is the measure of the heat inside the body; it is the
balance between heat produced and heat lost. The body generates heat as it
burns food. It loses heat through the skin and lungs, and body temperature
normally remains at approximately 37°C or 98.6°F1. If the temperature goes
much higher or lower than normal, it means that the balance is upset. The
body responds to fever by increasing the heart rate, breathing rate and
blood circulation to the skin. This is how the body tries to reduce the heat
caused by fever. With every degree Fahrenheit rise in the fever, pulse rate
goes up by 10 beats/min.
The signs of an elevated temperature are easy to recognize: a flushed
face, hot skin, unusually bright eyes, restlessness, and thirst. A lifeless
manner and pale, cold, and clammy skin are often signs of a subnormal
temperature.
Body tempature is usually lowest in the morning and highest in the late
afternoon and evening. The normal temperature for newborn infants and
children is usually higher than the normal adult temperature. Other
influences on normal body temperature include ovulation, childbirth, and
individual metabolism. Disproportionate increase in the pulse rate may
suggest early sepsis or primary cardiac disease.
The following conditions can cause a fever:
- infectious diseases;
- certain medications;
- heat stroke;
- blood transfusion;
- disorders in the brain.
Note. Never leave child unattended while you're taking his or her
temperature.
Types of Thermometers
1. Clinical thermometer is a hollow glass tube, or stem, with a
mercury- filled bulb on one end; the other end is sealed (Fig.4). Heat
expands the mercury, causing it to rise into the stem; the stem is marked off
in full degrees and in 2/10 of a degree. The markings range from 33.9°C or
34.45°C to about 42.2°C.The reading remains on the thermometer until you
briskly shake it down. They have some disadvantages. They measure
temperatures slowly and are often hard to read. If broken, they cause a
mercury spill which can be harmful and difficult to clean up.
There are two types of clinical thermometer tips: thin and slender and
bulb shaped.The thermometer with the bulb-shaped tip is used for taking
rectal temperature because it makes insertion safer. The slender-tipped oral
22
thermometer is used for taking temperature by mouth. Oral and rectal
thermometers must not be used interchangeably.
1 To convert Celsius to Fahrenheit, multiply by 96 and add 32. To change Fahrenheit to Celsius subtract 32
s/9.
and
multiply
by
23
Oral (slim and long bulbl
Чвао ?Ы»: on»
hundred ®rd twe ........
........ .... 4 - 4
<*ead this, one
hufifi«d point two
Rectal (round »rd
short bulbl
и ____ I « ____/
^Л
—!— J
Fig.4. Types of clinical thermometers
2. Digital electronic thermometer measures temperatures with a
heat sensor and require a button
battery (Fig.5). It measures
Fig.5. Digital electronic thermometer
temperature quickly, usually in less
than 30 seconds. The temperature is
displayed in numbers on a small
screen.The same thermometer can be
used to take both rectal and oral
temperatures.
3. Infrared ear (tympanic) thermometers use an infrared sensor to
О
measure the temperature of energy
radiating from eardrum (Fig.6). In
general, the eardrum temperature
provides a measurement that is as
accurate as the rectal temperature. The
Fig. 6. Infrared
biggest advantage of this thermometer is
ear
that it measures temperatures in less
thermometer
than 2 seconds. It also does not require
cooperation by the child and does not
cause any discomfort.
The tympanic thermometers may
not be accurate for newborns and require
careful positioning to get an accurate
reading.
9
4. Digital electronic pacifier thermometers have a heat sensor and are
powered by a button battery (Fig.7).
These pacifiers let measure oral
i
bf
temperature in younger children. They
are quite accurate if 0.5°F is added to the
digital reading. It takes approximately 3
minutes
to
get
a
reading.
Fig.7. Digital electronic pacifier
thermometer
25
5. Temperature strips put on
the forehead have been studied and have been found to be inaccurate. They
do not detect an elevated temperature
in most children with fever. Touching
the forehead is somewhat reliable for
detecting fevers over 102°F (38.9°C)
Fig.8. Temperature strips
but tends to miss mild fevers (Fig.8).
6. The Temporal Scanner Thermometer is a totally non-invasive system with advanced infrared technology
providing maximum ease of use with quick, consistently accurate measurements (Fig.9). The Temporal Scanner has patented software, providing
arterial heat balance. Advanced, patented technology measures temperatures
with a gentle stroke across the forehead. With a gentle схем
stroke of the forehead it captures the naturally emitted е»
ja&jj
heat from the skin over the temporal artery, taking
1,000 readings per second, selecting the most accurate. With its patented
Arterial Heat Balance system the Temporal Scanner measures ambient
temperatures, mathematically replaces the small temperature loss from
cooling at the skin, and displays an accurate arterial temperature.
Technique of taking body temperature
How to take oral temperature?
The oral method is the easiest to use,
and patients do not find it as
Fig. 9. The Temporal Scanner
uncomfortable as other sites.The oral
Thermometer
method is not used if the patient is
unconscious, delirious, or otherwise not responsible for his or her actions.
This method also is not used with an infant or young child, because of the
danger of injury from a broken thermometer. It is
contraindicated in surgery or injury to the nose or
mouth or in conditions in which the patient must
breathe through the mouth (Fig.10).
1. Be sure a child has not had a cold or hot
drink in the last 30 minutes.
2. If you are using a digital thermometer, turn
it on.
3. Place the tip of the thermometer under one
Fig.10. Taking oral
side of the tongue and toward the back. An accurate
temperature
temperature depends on putting it in the right place.
4. Have a child hold the thermometer in place
with his lips and fingers
26
(riot his teeth). He should breathe through his nose, keeping his mouth
closed. If a child can't keep his mouth closed because his nose is blocked,
suction out the nose.
5. Leave the digital thermometer in
the mouth until you hear the correct an oral temperature over 99.5°F
signal (usually a series of beeps).
6.
Read the temperature. Fever is
(37.5°C).
How to take an electronic pacifier
temperature?
1.
Have a child suck on the pacifier
until the temperature stops changing and
you hear a beep (Fig.11j.This usually
takes 3 to 4 minutes.
2.
Read the temperature. A child Fig.11. Taking an electronic pacifier
temperature
has a fever if the pacifier temperature is
over 37.8°C.
:u
How to take a rectal temperature?
The rectal temperature is the most acc
in
rate because the thermometer is placed
F
an enclosed cavity. It is recommended f
or
children younger than age 6 or for
n
anyoi who cannot hold an oral
e
thermometer the mouth.
in
Rectal temperatures are always
taken |
with unconscious or irrational patients
and Fig.12.Taking a rectal with
infants and young children unless contemperature
traindicated.
For easier insertion, a lubricated probe cover is used. The method is
con- traindicated in such conditions as diarrhea, rectal disease, or following
rectal surgery.
1. If you are using a digital thermometer, turn it on.
2.Have a child lie belly-down across your lap or on a firm, flat surface
and keep your palm along the lower back (Fig.12).
3. Before you insert the thermometer, put some water-based lubricating
jelly on the end of the thermometer and on the opening of the bottom (anus).
4. Insert the thermometer gently into the bottom about 1.3 cm for an infant and 3.8 cm for an adult. Gently direct the thermometer along the rectal
wall toward the umbilicus.This will avoid perforating the anus or rectum or
breaking the thermometer. It will also help ensure an accurate reading
because the thermometer will register hemorrhoidal artery temperature
27
instead of fecal temperature. Never try to force it past any resistance. Forcing
could
damage
the
bowel.
28
5. Hold a child still while the thermometer is in.
6. Take the thermometer out when you hear the correct signal (usually a
series of beeps) and write down the number on the screen, noting the time of
day that you took the reading.
7. Clean the digital thermometer's tip with cool, soapy water, or wipe it
with 70 % isopropyl alcohol. Then wipe the patient's anal area to remove any
lubricant or feces.
After a thermometer has been used to take a rectal temperature, do not
use it to take an oral temperature. Rectal temperature is generally higher than
oral and armpit temperature. The normal rectal temperature of a child is between 36.7 °C and 37.9°C.
How to take an armpit (axillary)
temperature?
Axillary (armpit) temperatures are
taken
only
when
conditions make it impossible to use any
other
method.
The
I
axillary method, however, is routinely used
for newborns after the
initial rectal reading. The axillary
temperature is the least
accurate because the skin surfaces in the
axillary space may not
come together to form a tightly closed
cavity
around
the
Fig.13.Taking an axillary thermometer tip.
temperature
1. Place the tip of the thermometer in a dry armpit (Fig.13).
2. Close the armpit by holding the elbow against the chest for 4 or 5
min. Do not remove it before 4 min have passed.
3. Remove the thermometer after you hear the signal (usually a series of
beeps) and read the temperature on the screen.
4. The child has a fever if the armpit temperature is over 37.2°C.
How to take temporal artery (ТА) temperature?
TheTemporal Scanner is fast accurate, easy to use
and gentle enough to be used even on a sleeping
patient. The thermometer reads the infrared heat
waves released by the temporal artery which runs
across the forehead just below the skin.
1. Place the sensor head at the center of the
forehead midway between the eyebrow and the „ A ^
.,
.
.
,.
/r.
1,
g.14. Taking a temporal
ha.rl.ne (F.g.14).
Fi
artery temperature
2. To scan for a child's temperature, depress
the scan button and keep it depressed.
3. Slowly slide the ТА thermometer straight across the forehead toward
the
29
top of the ear keeping in contact with the skin.
4. Stop when you reach the hairline and release the scan button.
5. Remove the thermometer from the skin and read a child's temperature
on the display screen.
How to take an ear temperature (syn. tympanic)?
1.
If a child has been outdoors on a cold
day, he needs to be inside for 15 minutes before
taking the temperature. (Earwax, ear infections,
and ear tubes, however, do not interfere with
acurate readings.)
2.
Pull the ear backward to straighten the
ear canal (Fig.15).
3.
Place the end of the thermometer into a
Fig.15. Taking an ear
child's ear canal and aim the probe toward the
temperature
eye on the opposite side of the head. Then press
the button. In about 2 seconds you can read the
temperature.
4. A child has a fever if the ear temperature is over 38°C.
How to take a forehead temperature?
1. Make sure the forehead is clean and dry.
2.
Firmly apply the thermometer onto the
middle of the forehead, holding it at both ends,
without touching the numbers (Fig.16).
3.Wait until colors stop changing, usually
Fig.16. Taking a forehead 15 - 20 sec.
temperature
4. For the correct temperature, read the green color only.
5. Disregard blue and tan colors.
6. Do not use the thermometer directly exposed to sunlight or very
bright lamps.
Counting Respirations
Breathing should be counted for one full
minute (60 sec). If the breathing is regular, it
can also be counted for 30 seconds and the
number multiplied by two.
Prepare to count respirations by keeping
fingertips on the patient's pulse. (A patient
who knows you are counting respirations may
not breathe naturally.)
Count respirations for 1 full minute
for an infant, holding the stethoscope at the
nos- Fig. 17. Counting respirations trils (Fig.17). Children normally have an
irregular, ЬУstethoscoPe m mfant more rapid rate.
30
Respirations can also be counted by
placing a hand lightly on the patient's chest
or abdomen (Fig. 18). Observe the rise and
fall of the patient's chest or one inspiration
and one expiration. One full cycle of
respiration consists of an inspiration and an
expiration.
Adults with an irregular rate require
Table 1
Normal respiration ranges (breaths per min)
Age
Range
newborn
1-2 years
5-6 years
40-60
30-35
up to 25
lOyears
Adults
18-20
15-16
more careful assessment including depth and rhythm of respirations).
Fig.18.Counting respirations
by placing a hand on the patient's chest
Table 1 lists normal ranges of respiration for different ages.
Assessing the pulse
The pulse is the number of heartbeats per minute.
Measuring the pulse can give very important information about the
health of a person. Any deviation from normal heart rate can indicate a
medical condition. Fast pulse may signal the presence of an infection or
dehydration. In emergency situations, the pulse rate can help determine if the
patient's heart is pumping. The pulse measurement has other uses as well.
During exercise or immediately after exercise, the pulse rate can give
information about the fitness level and the health of a person.
Common pulse sites (Fig. 19)
Axillary pulse: located inferiorly of the lateral wall of the axilla.
Apical pulse: located in the 4th or 5th left intercostal space, just to the
left of the sternum. In contrast with other pulse sites, the apical pulse site is
unilateral, and measured not over an artery, but over the heart itself (more
specifically, the apex of the heart).
Brachial pulse: located between the biceps and triceps, on the medial
side of the elbow cavity, frequently used in place of carotid pulse in infants
(brachial artery).
Carotid pulse: located in the neck (carotid artery). The carotid artery
should be palpated gently and while the patient is sitting or lying down.
Stimulating its baroreceptors with vigorous palpitation can provoke severe
31
bradycardia or even stop the heart in some sensitive persons. Also, a person's
two
32
carotid arteries should not be palpated at the same time. Doing so may limit
the flow of blood to the head, possibly leading to fainting or brain ischemia. It
can be felt between the anterior border of the sternocleidomastoid muscle,
above the hyoid bone and lateral to the thyroid cartilage.
Dorsalis pedis pulse: located on top of the foot (dorsalis pedis artery).
Femoral pulse: located in the thigh, halfway between the pubic
symphysis and anterior superior iliac spine (femoral artery).
Popliteal pulse: located behind the knee in the popliteal fossa, found by
holding the bent knee. The patient bends the knee at approximately 124°, and
the physician holds it in both hands to find the popliteal artery in the pit
behind the knee.
Radial pulse: located on the lateral of the wrist (radial artery).
Temporal pulse: located on the temple directly in front of the ear
(superficial temporal artery).
Tibialis posterior pulse: located on the medial side of the ankle (facing
inwards) behind the medial malleolus (posterior tibial artery).
Reading a pulse
Pulses are manually palpated with fingers. When palpating the carotid
artery, the femoral artery or the brachial artery, the thumb may be used.
However, the thumb has its own pulse which can interfere with detecting the
patient's pulse at other points, where two or three fingers should be used.
Fingers or the thumb must be placed near an artery and pressed gently
against a firm structure, usually a bone, in order to feel the pulse. To obtain a
reasonably accurate resting pulse rate, make sure the person is calm and has
been resting for 5 min before reading the pulse. Bear in mind that any
stimulants, taken prior to the reading will affect the rate. Place fingertips of
first, second and third fingers over the artery, and count the pulse beats for 1
full minute.
Table 2 lists normal ranges of pulse for various ages.
Table 2
Pulse ranges (heartbeats per minute)
Age
Newborns
7-12 mo
3 years
5-6 years
Range
140-160
120
105
100
10 years
Adults
80-85
70-80
Normal ratio of pulse and respiration in health is4:1.The ratio is
increased in primary cardiac disease and decreased in respiratory pathology.
33
Fig. 19. Common pulse sites: A- a. temporalis.В - a. carotis.С - a. radialis on both hands. D- a. radialis on one hand. E -a. ulnaris. F -a.
femoralis. G- a. poplitea. H- a. tibialis posterior. I- a. dorsalis pedis.
Measuring the blood pressure (BP)
Blood pressure is the force exerted on the walls of blood vessels as blood
flows through them. The heart is like a pump. When it contracts, it sends a
surge of blood through the blood vessels and pressure increases. This is called
systolic pressure. When heart relaxes between beats, blood pressure
decreases. This is diastolic pressure.
When we take the blood pressure, we measure both systolic arterial
pressure (SAP) and the diastolic one (DAP), and record them as numbers. For
example, if a blood pressure reading is 126/76, the systolic is -126 and the
diastolic - 76.The numbers are calculated in millimeters of mercury and
recorded
as
126/76
mmHg.
34
The blood pressure varies during the day. The factors influencing the blood
pressure include physical activity,
medications, emotional and physical
condition.
Blood pressure measurement using
the sphygmomanometer
To take the blood pressure, the person
should be sitting comfortably and
relaxed (Fig 20).
1.
Position the patient's arm so
the anticubital fold (inside elbow area) Fig. 20. Measuring blood pressure
is level with the heart. Support the pausing the sphygmomanometer
tient's arm with your arm or a bedside
table.
2.
Center the bladder of the cuff over the brachial artery approximately 2
cm above the anticubital fold. The arrow should line up with the artery. Proper
cuff size is essential to obtain an accurate reading. Be sure the index line falls
between the size marks when you apply the cuff. Position the patient's arm so
it is slightly flexed at the elbow.
3. Palpate the radial pulse and inflate the cuff until the pulse disappears.
This is a rough estimate of the systolic pressure.
4. Place the stethescope diaphragm over the brachial artery and the
earpieces in your ears.
5. Inflate the cuff to 30 mmHg above the estimated systolic pressure and
hold it there by tightening the knurled knob.
6. Release the cuff pressure slowly by turning the knurled knob just until
you hear the hiss of air being released (no greater than 5 mmHg per second).
7. The level at which you consistantly hear the heartbeats through the
stethescope is the systolic pressure.The needle on the gauge should also start
a pulsing movement at this point. Record this value as the systolic pressure.
8. Continue to release the cuff pressure until the sounds muffle and
disappear. The point at which you no longer hear sounds and the needle on
the gauge stops its pulsing movement is the diastolic pressure. Record the
value from the gauge.
9. Record the blood pressure as systolic over diastolic ("120/70" for example).
What do you hear while measuring BP?
Phase 1.A loud, clear tapping (or snapping) sound is evident, which increases in intensity as the cuff is deflated.
Phase 2.A succession of murmurs can be heard. Sometimes the sounds
seem to disappear during this time (auscultatory gap). This may be a result of
inflating or deflating the cuff too slowly.
35
Phase 3.A loud, thumping sound, similar to phase I but less clear,
replaces
the
murmurs.
36
Phase 4.A muffled sound abruptly replaces the thumping sounds of
phase 3.
Phase 5.All sounds disappear. This phase is absent in some people. The
pressure at which the sound becomes muffled (beginning of phase 4) and the
pressure at which the sound disappears (beginning of phase 5) are taken as
measurements of diastolic pressure. Phase 5 is closer to the true value,
however, phase 4 is easier to detect and the measurements are more
reproducible.
Blood goes through the arteries in a laminar flow, that is, blood in the
central axial stream moves faster than that in the peripheral layers, with little
or no transverse flow (mixing) between layers. Therefore, at rest, the artery is
silent when auscultated.
When the sphygmomanometer bag is inflated to a pressure above the
systolic pressure, the flow of blood is stopped and the artery is again silent.
As pressure in the bag drops to levels between the systolic and diastolic
pressures of the artery, the blood is pushed through the compressed walls of
the artery, creating turbulent flow. Now, the layers of blood are mixed by
eddies that flow at right angels to the axial stream, causing turbulence and
vibrations in the artery that are heard as sound in the stethoscope.
Blood pressure measurement using a digital monitor
Because the digital monitor is automatic, it is the most popular
blood-pressure measuring device. The blood pressure measurement is easy
to read, because the numbers are shown on a screen (Fig.21).
The digital monitor is easier to use. It has a gauge and stethoscope that
are one unit, and the numbers are easy to read. It also has an error indicator,
and deflation is automatic. Inflation of the cuff is either automatic or manual,
depending on the model. This blood pressure monitoring device is good for
hearing- impaired patients, since there is no need to listen to heart sounds
through the stethoscope.
1. Put the cuff around the arm. Turn the power on, and start the machine.
2. The cuff will inflate by itself with a push of a button on the automatic
models. On the semiautomatic models, the cuff is inflated by squeezing the
rubber bulb. After the cuff is inflated, the automatic mechanism will slowly
reduce the cuff pressure.
3. Look at the display window to see blood pressure reading. The
machine will show systolic and diastolic blood pressures on the screen. Write
down blood pressure, putting the systolic pressure before the diastolic
pressure.
4. Press the exhaust button to release all of the air from the cuff.
To repeat the measurement, wait 2 to 3 minutes before reinflating the
cuff.
37
Л
Fig. 21. Measurement of blood pressure using a digital monitor
Routine blood pressure measurements in children may be performed in
children beginning around age 3 years. In younger children and infants,
measure the blood pressure only if the history or physical exam suggests a
problem.
As in adults, proper cuff size is essential. The bladder width should
cover no more than 2/3 of the child's upper arm and the bladder length
should cover approximately 3/4 of the arm circumference. A cuff that is too
small will inflate the pressure reading and a large cuff will give an artificially
low pressure.
Unlike in adults, the diastolic reading in children is the point at which the
sounds first become muffled rather than the point at which they disappear
completely.
Sustained hypertension over several readings in children should prompt
a search for its cause. In infants and young children hypertension is most
often due to a specific cause. In older children and adolescents, a specific
cause is less likely to be found and may resolve by adulthood.
BP is relatively low in infants owing to the low pumping force of the heart
and the greater width of the vessels, and the greater elasticity of the arterial
walls.
Normal blood pressures vary with age (Table 3).
Table 3
Average blood pressure in normal children (mmHg)
Age
Systolic BP
Diastolic BP
Birth
70
35
6mo
90
lyr
90
2yr
92
1/2-1/3of Systolic BP
6yr
95
1 /2-1 /3of Systolic BP
8yr
100
1/2-1/3of Systolic BP
lOyr
105
1/2-1/3of Systolic BP
1/2-1/3of Systolic BP
60
38
BP values after one-year also can be calculated by the following formula:
- systolic blood pressure averages 90+2n.
(Max. level -105+2n and Min. level-75 + 2n);
- diastolic blood pressure averages 60+n
(Max. level -75+n and Min. level - 45 + nj,
where "n" Is the child's age in years.
The sum of the pulse rate and SBP values in all periods of childhood after
1 year old is about 200.
The information about vital signs are registered into the temperature
chart (see Appendix 2).
2.3. The oral administration of drugs
Because oral administration is usually the safest, most convenient, and
least expensive method, most drugs are administered by this route. Drugs for
oral administration are available in many forms: tablets, enteric-coated
tablets, capsules, syrups, elixirs, oils, liquids, suspensions, powders, and
granules. Some require special preparation before administration, such as
mixing with juice to make them more palatable; oils, powders, and granules
most often require such preparation.
Sometimes oral drugs are prescribed in higher dosages than their
parenteral equivalents because after absorption through the Gl system, they
are immediately broken down by the liver before they reach the systemic
circulation.
The oral route is convenient and economical but has drawbacks. Some
drugs have an unpleasant taste or odor; others injure the teeth or irritate the
lining of the stomach. Patients who are nauseated or vomiting cannot take
drugs by mouth. Digestive enzymes destroy the effectiveness of certain drugs.
In some instances, patients may be uncooperative and refuse to swallow the
medication. Furthermore, there is the danger of an unresponsive patient
aspirating a medication into the lungs. Patients should be told if a solid
medication is to be chewed or swallowed wholly.
Children are not to be given medicinal agents into hands. The nurse must
be sure the child has swallowed the pill and washed it down with little frequent
draughts.
As for little children, it is better to introduce peroral medicinal agents as
liquids (syrups, drops). However, in case of necessity, pills may be triturated,
and in order to ease swallowing and aspiration prophylaxy of respiratory tract,
the obtained powder is to be dissolved in a small quantity of liquid. As for
infants, it is better to divide the prescribed dose of medicinal agent into some
consequent small draughts.
Sublingual administration. A sublingual (SL) drug is placed under the
patient's tongue, where it dissolves and is absorbed. Some medication used
for certain emergencies are given via this route. They should be placed under
the tongue until they are dissolved, trying not to swallow saliva for the longest
time possible. The patient must be able to understand instructions to keep the
39
drug under the tongue and not chew or swallow it. The patient should not
drink anything until the drug is absorbed.
Buccal administration. Buccal refers to the cheek or mouth. Buccal administration involves placing the medication between the cheek and gum.
Actions will depend on patient's ability to self-administer the medication. If
patient requires assistance, the nurse must wear gloves.
2.4. The anthropometrical measurement in children of different ages
Anthropometry (from Greek"anthropos"- human being, and"metron"measure) is the method of examination based on the comparative
measurements of morphological and functional signs of the human
individual.
Infant length
Infant is measured in a clean dry diaper on a calibrated length board, 80
cm long and 40 cm wide (Fig.21, A). There is a motionless cross plank at the
beginning of the board. At the end of the scale there is a mobile cross plank
easily moving on a scale.
1. Measure length for children less than 24 months of age or children
aged 24-36 mo who can not stand unassisted.
2. Measure infant without shoes and wearing light underclothing or
diaper.
3. Hold the infant's head in such a position that the lower corner of an
eye- socket and the upper edge of an ear tragus are on one line.
4. Straighten the legs by easy pressing knees.
5. The measurer aligns the infant's trunk and legs, extends both legs,
and brings the footboard firmly against the feet.
6. The distance between the mobile and the motionless planks
corresponds to the child's height.
7. Write length measurement on chart.
The accuracy (precision) of such measuring is ±0,5 cm.
Infant weight
Infant is weighed nude or in a clean diaper on a calibrated beam or electronic scale (Fig.21, B).
1.Remove infant's clothing or be sure the diaper is clean and dry.
2. Center the infant on the scale tray.
3. Weigh infant to nearest 0.01 kg, 10 gm.
4. Write the weight on the infant's chart.
5. Reposition and repeat weighing the infant.
Compare weights.Weight should agree within 0.01 kg, 10 gm.
6. If infant is too active, postpone the measure until later or have parent
step on scale, tare scale to zero, have parent hold infant and note infant
weight.
40
Measurement of head circumference
Head is measured with a flexible, nonstretchable tape over the most
prominent part of the occiput and just above the supraorbital ridges (Fig. 21,
C).
1. Position the tape just above the eyebrows, above the ears, and around
the biggest part of the head.
2. Pull
tape
snugly
to
compress
the
hair.
41
3. Read the measurement to the nearest 0.1 cm.
4. Write the measurement on the chart.
5. Measures should agree within 0.2 cm.
Chest circumference in infant is measured in supine position at rest
(Fig. 21, D).
1. Position the tape on the back just below the angles of scapulae, in
front - above the nipples.
2. Pull tape snugly to compress the chest.
3. Read the measurement to the nearest 0.1 cm.
4. Write the measurement on the chart. Measures should agree within
0.2 cm.
A) Measurement of infant length
__ ^ i
Measuring
the
girls
in
B) Weighting an infant
C) Measurement of head
circumference
Fig. 21. Anthropometrical
measurement of an infant
puberty age, position
the tape above the
mammary glands at
the level of the fourth
D) Measurement of chest circumference
rib. Measuring of the
children at more
advanced
age
is
performed in a standing position (arms dropped, calm breath). Chest
measuring is carried out at full inhalation and full exhalation and at calm
breath.
42
Child and adolescent weight
Child older than 36 months or adolescent are weighed standing on a
beam balance or electronic scale. The beam balance consists on two scales,
the accuracy of weighting is 50,0 g (Fig. 22).
1. Child must stand without assistance.
2. Child or adolescent is wearing lightweight undergarments, gown, or
43
negligible outer clothing.
3. While being weighted, a child or adolescent must stand motionless
on the center of a balance platform.
4. Read the measurement and record it on the chart.
5. It is recommended to do weighing in the morning on an empty
stomach and it is desirable after urination and defecation.
Child and adolescent height
The measuring is carried out with a height meter, a wooden board 2
meters and 10 centimeters long, 8 or 10 centimeters wide, 50x75 cm
thick.Two scales (in centimetres) are marked on the vertical board: one (to
the right) is for height measuring in a standing position; another (to the left)
is for height measuring in a sitting position (Fig. 23 A, B). A plank 20 cm
long slides on it. On the level of 40 cm from a floor there is a folding bench
attached to the vertical board for the height measuring in a sitting position.
Child or adolescent is measured without shoes, outer clothing or hair
ornaments on calibrated stadiometer.
The order of measuring:
1. Measure stature for children over age three.
2. Use a calibrated vertical stadiometer with a right-angle headpiece.
3. The child is measured standing with heels, buttocks, and shoulders
touching a flat upright surface.
4. Child or adolescent should stand on the stadiometer footplate
without shoes. With heels together, legs straight, arms at sides, shoulders
relaxed.
5. Child looks straight ahead.
6. Bring the perpendicular headboard down to touch the crown of the
head.
7. Measurer's eyes should be parallel with the headboard.
8. Read the measurement to the nearest 0.1 cm and record it on the
chart.
Measures
should
agree
within
1
cm.
44
Fly.
a
Fig.AA.vvciyiiiiny
23. Height measuring
over age three:
in a sitting
A A. in a standing position B. В
V.HHU over age three
position
45
2.5. Medical care in fever
In children, a fever that is equal to or greater than 38.5° С should be
treated. Children between the ages of 6 months and 5 years can develop
seizures from a high fever (called febrile seizures). If a child does have a
febrile seizure, there is a chance that the seizure may occur again, but,
usually, children outgrow the febrile seizures. A febrile seizure does not mean
that child has epilepsy.
There are different things that can be done to take care of a fever. Since
fevers work in the body to fight off infection, medicine should only be given if
needed. For example, if the oral temperature is over 39°, Acetaminophen
(Tylenol) or Ibuprofen (Advil) may be given. Aspirin is dangerous for children.
When a child has a fever, he or she needs to stay well hydrated. The child
should drink a lot of healthy liquids like water, milk or 100 % juices. It should
be remembered that the increase of temperature on Г С requires introduction
of liquid of 10 ml/kg of body weight.
A child with a fever should be kept comfortable and not overdressed.
Overdressing can cause the temperature to rise further. If the fever is still over
40.0° 30 min after medicine is given, the child should be given a sponge bath.
A sponge bath involves sponging off a child in a bathtub with a lukewarm
water.
Heat removal is generally by wet cloth or pads, usually applied to the
forehead, but also through bathing the body in tepid water. This is particularly
important for babies, where drugs should be avoided. Tepid water (30° C)
baths may help bring down a fever. Use lukewarm water (32.22° to 35°).
Sponge for 20 to 30 minutes. Stop if the child starts to shiver. If a child doesn't
like the sponge bath or doesn't feel better after the bath, there is no need to
give another one.
Never use cold water or alcohol for a sponge bath to reduce fever, because:
A. Cold water can cause vasoconstriction and shivering, which raises the
central body temperature.
B. Alcohol reduces fever too rapidly and may lead to convulsions,
especially in a small child.
C. Alcohol fumes are toxic.
D. Both can make the child uncomfortable.
Sponge with tepid water
A. Child may be placed in tub for sponge bath or in bed using a basin of
water.
B. Use gentle friction and slowly stroke the wet washcloth over body.
C. Sponge for 12-30 minutes unless child becomes chilled.
D. Pat child dry with a towel and redress in lightweight clothing.
E. Take child's temperature immediately after discontinuing sponging
and again 30 minutes later.
Documentation
1. Time and duration of sponging.
2. Temperature and other vital signs.
3. How procedure tolerated, including child's response.
46
Tests for self-training
Q1. If an infectious disease is revealed in a child, an urgent report should
be sent to:
Dermatovenereologic dispensary.
Police.
Sanitary-epidemiological station.
Local health authorities.
Children's polyclinic.
Q2.The normal adult range for respirations per minute is:
A. 26-40.
B. 20-30.
C. 18-24.
D. 16-20.
Q3.Vital signs include the temperature, pulse, respirations, and
A. Weight.
B. Blood pressure.
C. Height.
D. Head circumference.
Q4. Which temperature is lowest and least accurate?
A. Axillary.
B. Rectal.
C. Oral.
D. Tympanic.
Q5.Which of the following is important when measuring the oral temperature?
A. The patient must be able to breathe through the nose.
B. Place the thermometer on top of the tongue and in the center.
C.The patient should hold the thermometer between the teeth.
D. Wait 5 minutes after a patient eats or drinks before taking the
temperature.
Q6. Which of the following is part of the procedure for weighing an infant?
A. Weigh the infant dressed.
B. Place the child face down on the scale.
C. Keep one hand over the child all the time.
D. Measure the weight within one pound.
Q7. Systolic pressure at the age of 8 year should be:
A. 85-90 mm Hg.
B. 105-110 mm Hg.
С. 70-75 mm Hg.
D. 110-115 mm Hg.
E. 120-130 mm Hg.
Q8. The best form of a peroral drug administration for younger children
is:
A. Pill.
B. Powder.
C. Capsule.
D. Syrup.
E. Mixture.
Q9. The respiration rate in a 12-year-old child is 28 per minute, that
corresponds to:
A. Bradypnoea.
B. Norm.
С. Tachypnoea.
D. Arrhythmia.
E. Tachycardia.
F. Bradycardia.
Q10. When a child is admitted to inpatient department, the nurse does
everything but:
A. assessment of the physical development;
B. filling in of the title page of the case history;
47
C. giving first aid;
D. anthropometry;
E. physical examination.
Key answers: Q1 -C; Q2- D; Q3 -B; Q4- A; Q5- A; Q6 -C; Q7 -B; Q8 -E;
Q9-C;Q10-A.
48
CHAPTER 3.
PROVIDING OF MEDICAL AND DIAGNOSTIC PROCESS IN CHILDREN'S HOSPITAL
3.1. Stool specimen collection for testing. Preparation of patients and
necessary equipment for taking feces for ova and parasites, fecal occult blood
test, hematest reagent tablet test, enterobiasis tape test
Stool collection
Feces, also called stools or bowel movements (BM), are an important
source of information about the digestive system. Stool is collected to
determine the presence of inflammation, or obstruction or blood, ova and
parasites, bile, fat, starch, connective tissue or undigested muscle fibers,
leucocytes, erythrocytes, epithelium. Because the food mass loses water as it
moves along, liquid feces indicate a rapid movement, whereas hard feces
indicate that slower passage has occurred or that the feces have been in the
rectum for some time. The process of expelling stool or feces is called
defecation. Feces can also be tested for fecal proteolytic activity, which is a
reflection of the pancreas'ability to produce protease enzymes. Macroscopic
examination of stool is perfomed for evaluation characteristics, such as color,
consistency, odor, mucus, pus, blood.
Collecting specimens promptly and correctly can directly affect a
patient's diagnosis, treatment, and recovery. In many cases, the nurse is solely
responsible for collecting appropriate specimens. Even for tests that are not a
nurse's hands- on responsibility, you may have to schedule the test, prepare
the patient, assist the physician or other caregiver in performing the test, and
care for the patient afterward. For some tests, for example, you may have to
teach the patient how to perform the procedure at home, as with blood
glucose tests and fecal occult blood tests.
A thorough working knowledge of diagnostic tests will help you prepare
patients for them. If you can explain a test with clarity and compassion, you'll
help put the patient at ease, gain his trust and cooperation, and thus ensure
more accurate results. Helping him understand a procedure based on the
physician's explanations also paves the way for consent that's truly informed.
When preparing a patient, your explanations should be clear,
straightforward, and complete. For example, before a difficult or painful
procedure, warn the patient about the type of discomfort he'll probably feel.
Letting him know exactly what to expect helps him tolerate such a procedure.
Preparation should include telling the patient how long the procedure takes
and how soon the results will be available.
Note. Never place a stool specimen in a refrigerator that contains food or
medication to prevent contamination.
Documentation
Record the time of specimen collection and transport to the laboratory.
Note stool color, odor, and consistency, and any unusual characteristics; also
note
whether
the
patient
had
difficulty
passing
the
stool.
49
Collecting a stool for ova and parasites
This test indicates the presence of intestinal parasites and/or their eggs
(ova), which can cause gastrointestinal symptoms and disease.
1. The patient should be instructed notto take any antacids, oily
laxatives, or anti-diarrheal medications, unless prescribed by the physician.
2. Wash your hands and put on gloves.
3. Explain the procedure to the person and ask the person to tell you
when the urge to have a bowel movement is felt.
4. Label the container with the patient's first and last name, date of
birth, and the date and time of collection of the sample.
5. Collect stool sample into a clean dry container such as a disposable
food container, or onto plastic wrap stretched under the toilet seat.
6. Take a portion of feces from three different areas of the stool
specimen.
7. Cover the container. Note any special examination requested.
8. For sanitary reasons, the container must be enclosed in a plastic bag.
Properly dispose of gloves and wash your hands thoroughly after collection.
9. Deliver the stool sample to the laboratory as soon as possible. Stool
should be examined when fresh. Examinations for parasites, eggs (ova), and
organisms must be made when the stool is warm.
Special Considerations in Children
When an infant has diarrhea and the stool specimen is to be examined,
place the diaper in a biohazard bag, label it, and take or send the diaper to the
laboratory immediately. Otherwise, remove the stool from the diaper.
Enterobiasis (Pinworm infection) is a large intestine infection caused by a
small, white worm called a pinworm, seatworm, or threadworm. The medical
name for the pinworm isEnterobius vermicularis, also called a helminth. The
disease is highly contagious and generally is spread by inadequate
handwashing from infected persons.
The adult female worm is about the size of a
staple (approximately 1 cm long and 0.5 mm
wide) and has a pointed tip.(Fig.24).The disease
is transmitted by ingesting the eggs of the
pinworm. These eggs travel to the small
intestine where, after approximately one
month, they hatch and mature into adult
worms. During the night, the female adult Fig. 24. The adult female
worms travel to the area around the anus and
worm
deposit eggs in the
folds of the anal area. A single female pinworm
can lay 10,000 eggs and, after laying eggs, dies. The eggs are capable of
causing infection after 6 h at body temperature.
While an infected person is asleep, female pinworms leave the intestines
through the anus and deposit eggs on the skin around the anus. Intense
itching around the anus and/or vagina comprise the classic symptoms of
pinworms.
Less common symptoms range from upset stomach to loss of appetite,
irritability, restlessness, and insomnia.
School-age children have the highest rates of pinworm infection. They
are followed by preschoolers. Pinworm infection often occurs in more than
one family member.
To relieve the rectal itching, a shallow warm bath with half a cup of table
salt is recommended. Also, application of an ointment containing zinc oxide
or regular petroleum jelly can be used to relieve rectal itching.
Enterobiasis tape test
Alternative names: Oxyuriasis test; Pinworm test.
Enterobiasis tape test or transparent adhesive tape test (sometimes called
a Scotch tape test) refers to a method used for collecting and examining
material gathered from regions surrounding the anus. This test is usually used
to identify an infection of pinworms by collecting both the worms and eggs.
The best time to perform this test is at night or as soon as the individual
wakes up in the morning, before having a bowel movement or taking a bath or
shower. The pinworm eggs will stick to the tape, which can then be placed on
a specimen slide. When under a microscope in the laboratory, the eggs will be
clearly visible.
The sticky slide of the adhesive is patted on the anus and the perianal regions of the person who is thought to be infected with pinworms. The
adhesive is then stuck onto the slide and read under a microscope by a
professional, who should easily be able to tell if there is an infection or not.
One test is not always enough to successfully diagnose enterobiasis and more
than one may have to be done. A repeated test done everyday for three days
straight will diagnose enterobiasis over 90% of the time.
At revealing helminthic invasion in the child, all members of family
should undergo this medical test. And all of them should be treated
irrespectively of the results of tests.
Samples taken from under the fingernails may also contain eggs (since
scratching of the anal area is common by affected individuals).
Because the infection is easily spread through contact with contaminated
clothing or surfaces, it is recommended that all family members receive the
therapeutic dose.
Fecal occult blood test
This analysis is prescribed for finding out the presence of blood in
excrements (stool is collected in a clean vessel).
Fecal occult blood tests are valuable for determining the presence of
occult blood (hidden Gl bleeding) and for distinguishing between true melena
and me- lena-like stools. Certain medications, such as iron supplements,
activated carbon and bismuth compounds, can darken stools so that they
resemble melena.
Diet Guidelines
Because certain foods can alter the test results, a special diet is often
recommended for 48-72 h before the test. The following foods 51
should not be
eaten 48-72 h before taking the test: beets, broccoli, cantaloupe, carrots,
cauliflower, cucumbers, grapefruit, horseradish, mushrooms, radishes, red
meat (especially meat that is cooked rare), turnips, vitamin C-enriched foods
or beverages.
Two common occult blood screening tests are Hematest (an
orthotolidine reagent tablet) and the benzidine test (Gregerson test). Both
tests produce a blue reaction in a fecal smear if occult blood loss exceeds 5 ml
in 24 h.
Occult blood tests are particularly important for early detection of peptic
ulcer (in the stomach and duodenum), colorectal cancer. To confirm a positive
result, the test must be repeated at least three. Even then, a confirmed positive
test doesn't necessarily indicate colorectal cancer. It does indicate the need for
further diagnostic studies because Gl bleeding can result from many causes
other than cancer, such as ulcers and diverticula. These tests are easily
performed on collected specimens or smears from a digital rectal
examination.
Sometimes appearance of blood in the intestines is of some other reason:
- Eruption and dental treatment.
- Nasal bleeding.
- Injury of mucous membrane of oral cavity.
- Alimentary character - eating of poorly processed meat, liver.
Hematest (reagent tablet test)
- Use a wooden applicator to smear a bit of the stool specimen on the
filter paper supplied with the test kit or after performing a digital rectal
examination, wipe the finger you used for the examination on a square of the
filter paper.
- Place the filter paper with the stool smear on a glass plate.
- Remove a reagent tablet from the bottle, and immediately replace the
cap tightly. Then place the tablet in the center of the stool smear on the filter
paper.
- Add one drop of water to the tablet, and allow it to soak in for 5 to 10
sec. Add a second drop, letting it run from the tablet onto the specimen and
filter paper. If necessary, tap the plate gently to dislodge any water from the
top of the tablet.
- After 2 min, the filter paper will turn blue if the test is positive. Don't
read the color that appears on the tablet itself or that develops on the filter
paper after the 2-mi-nute period.
- Note the results and discard the filter paper.
- Remove and discard your gloves, and wash your hands thoroughly.
- Test sensitivity is 4ml of whole blood per 100 g of feces.
3.2. Collection of urine for Zimnitskiy, Nechiporenko tests.
Addis sediment count.
Chemical examination of urine. Urine culture
The urinalysis is used as a screening and/or diagnostic tool because it
can help detect substances or cellular material in the urine associated with
different metabolic and kidney disorders. It is ordered widely and routinely to
detect any abnormalities that should be followed up on. Often, substances
such as protein or glucose will begin to appear in the urine before patients are
aware that they may have a problem. It is used to detect urinary tract
infections (UTI) and other disorders of the urinary tract.
Urinalysis is done by collecting a urine sample from a patient. The
optimal sample tends to be an early morning urine sample because it is
frequently the most concentrated urine produced in the day.
Methods of collection are slightly different for female and male patient.
For females, the patient is asked to clean the area around the urethra
with a special cleansing wipe, by spreading the labia of the external genitals
and cleaning from front to back (toward the anus).
For men, the tip of the penis may be wiped with a cleansing pad prior to
collection. The urine is then collected in a clean urine specimen cup while the
patient is urinating. It is best to avoid collecting the initial stream of urine.
After the initial part of urine is disposed of in the toilet, then the urine is
collected in the urine container provided. Once about 30-50 ml are collected
in the container for testing, the remainder of the urine may be voided in the
toilet again.This is called the clean catch or the midstream urine collection.
The collected urine sample should be taken to the laboratory for
analysis, typically within 1 h of collection. If transportation to the lab could
take more than 1 h, then the sample may be refrigerated.
In some patients who are unable to void spontaneously or those who are
not able to follow instructions other methods may be used, such as placing a
catheter (a small rubber tube) through the outside opening to the bladder
(urethra) to collect the sample directly from the bladder.
Collecting urine in a urine collector
1. Wash your hands.
2. Gather needed supplies.
3. Explain to parents what you are going to do and why.
4. Position the child on his or her back with legs apart and knees bent
(frog-leg position). You may need the assistance of another adult to position
the child properly so you can accurately apply the collector.
5. Gently cleanse and dry perineal area. You may use plain water and a
wash cloth to cleanse the labia or penis. Remove any powder or lotion. (Clean,
dry skin is necessary for the adhesive to stick).
6. Peel backing off adhesive surface and apply bag to perineum. With
females, it is easiest to seal it from the bottom up to the pubis; do the
opposite with males. Be sure the skin is smoothed during application, by
gently pulling on the skin as needed.
7. With males, place the penis in the bag and apply the bag to the pubis
and scrotum. Be sure the foreskin is in its normal position in an uncircumcised
male before applying the bag.
8. Cover the bag with a loose-fitting diaper or underpants. (This
discourages the child from pulling on the bag. Tight-fitting diapers or pants may
dislodge the bag or cause the seal to burst after the child has voided.)
9. Offer fluids after the bag is applied. (This encourages voiding.)
10. Check the bag every 15 to 30min to see if the child has voided.
53
11. After the child has voided, gently remove the bag as soon as
possible.
12. Cleanse the perineum.
13. Apply a clean diaper or underpants.
14. Place the urine in a specimen cup through the emptying port
provided on the outside of the bag.
15.
Discard waste appropriately. Discard gloves.
16.Wash your hands.
17. Send specimen to the lab following your facility's policy.
18. Document that the specimen was
obtained.
Pediatric urine specimen collector employs a
urine collection bag provided with an
adhesive patch at one end having an opening which can surround the male or female
organ of children. In this manner, the urine
produced is directed to the plastic urine
collection bag connected to the adhesive
patch. (Fig.25).The drawback of the present
pediatric urine collector is that during actual Fig. 25. Collecting urine in a urine
collector
use a diaper is placed over the urine
collector bag covering the whole part of the
urine collector device.
Taking urine by the method of Nechiporenko. This method helps to determine the amount of cellular elements (WBC, RBC and casts) in 1 ml of urine.
Rules of collecting: in a clean vessel unless than 10 ml urine is taken
from the middle portion of the first morning urination.
The normal values by the method of Nechiporenko are:
WBC not more than 2,000/ml; RBC
not more than 1,000 /ml; Casts not
more than 200/ml.
Addis sediment count-quantitative estimation of urinary cellular excretion. Method for counting the sediment (casts and cells) in a 12-h (24 h) urine
sample.
Technique of urine collecting:
1. 1. The day before child should take high-protein and low-fluid diet
and should not drink at night-time.
2. 2. Collect all the urine into container during 12 hours (from 22 p.m
to 8 a.m.).
The normal values are:
WBC not more than 2,000,000 per 24h; RBC
not more than 1,000,000 per 24h; Casts not
more
than
20,000
per
24h.
55
Taking urine by the method of Zimnitskiy. This method helps to determine functional renal capabilities to osmotic concentration and dilution in
diurnal diuresis.
Technique of urine collection:
Collect 8 portions of urine per 24 h. Adult persons and elder children
perform this by voiding every 3 h (at 9.00, 12.00, 15.00, 18.00, 21.00. 24.00,
3.00 and 6.00). If the child needs to discharge between these hours, he
urinates into container marked by the next hour. In infants and young children
urine is collected during natural urinations, and the amount of containers is
equal the number of voidings.
While estimating the results, the following data are taken into account:
- daily volume of urine;
- correlation of daytime and nocturnal urine volume. (Normal
correlation of day time and night diuresis is 2:1 );
changes of specific gravity during 24 h.
(Normal values of specific gravity of urine
depend on age and must be different in
different portions (the difference between
maximum and minimum values must be
more than 0.007). The less this difference
tjtj
the worse the function of kidneys.
Chemical Examination of Urine Urine
Щ
dipsticks provide a quick and inexpensive
method for detecting abnormal substances
within the urine. Urine dipstick is a narrow
plastic strip which has several squares of
different colors attached to it (Fig.26). Each Fig. 26. Chemical Examination
of Urine
small square represents a component of the
test used to interpret urinalysis.The entire
strip is dipped in the urine sample and color changes in each square are noted.
The color change takes place after several seconds to a few minutes from
dipping the strip. If read too early or too long after the strip is dipped, the
results may not be accurate. The squares on the dipstick represent the
following components in the urine: (1) blood, (2) protein, (3) glucose, (4)
ketones, (5) urobilinogen and bilirubin, (6) white blood cells, (7) specific
gravity, (8) pH. Presence or absence of each of these color changes on the strip
provides important clues for doctor to make clinical decisions based on the
urinalysis results.
The main disadvantage is that the information may not be very accurate
as the test is time-sensitive. It also provides limited information about the
urine as it is qualitative test and not a quantitative test.
Urine Culture. A urine culture is used to identify urinary tract infections
and yeast by obtaining a sample of "clean-catch" (midstream) urine. Because
of the potential to contaminate urine with bacteria and cells from the
surrounding skin during collection (particularly in girls), it is important to first
clean the genitalia. In preparation for this test, males must clean the head of
the penis. Females need to wash the area between the lips of the vagina with
S
soapy water and rinse. The patient then gives the container containing the
urine
sample
to
their
health
57
care provider.
As the patient begins to urinate, they should allow a small amount to fall
into the toilet bowel to clear the urethra of any contaminates. Then, in a sterile
container, they should catch about 50-150ml and then remove the container
from the urine stream.
The urine sample should be sent out to a laboratory for evaluation within
2 h. With a urine culture, a small sample of urine is placed on one or more agar
plates (a thin layer of a nutrient gel) and incubated at body temperature. Any
microorganisms that are present in the urine sample grow over the next 24 to
48 h as small circular colonies. The size, shape, and colour of these colonies
give clues as to which bacteria are present, and the number of colonies
indicates the quantity of bacteria originally present in the urine sample.
A laboratorian observes the colonies on the agar plate, counting the total
number and determining how many types have grown. Ideally, if a good clean
sample was collected for the test (see below), then the only bacteria present
should be due to an infection. Usually, this will be a single type of bacteria that
will be present in relatively large numbers. Sometimes, more than one type of
bacteria will be present. This may be due to an infection that involves more
than one pathogen (disease-causing microorganism); however, it is more
likely to be due to contamination from the skin picked up during the urine
collection.
Based upon the information obtained, the laboratorian gives the doctor
an initial report of the quantities and types of bacteria (or yeast) present in the
urine. Pure culture isolates are identified and susceptibilities are performed at
counts greater than 104 colonies/mL, if appropriate.
Examples would be: "no growth in 24 h" (nothing grew on the agar), "less
than 10,000colonies/ml" (a small amount of bacteria is present) or "greater
than 50,000 colonies/ml of gram negative rods, ID and susceptibility to
follow" (the patient probably has an infection caused by a gram negative
bacteria that needs to be further identified).
If there is no or little growth on the agar after 24 to 48 h of incubation,
the urine culture is considered negative for pathogens and the culture is
complete. If there is one or more pathogen present, further testing is
performed.
3.3. Collection of a nose and throat swab
Collection normally involves sampling inflamed tissues and exudates
from the throat, nasopharynx, with sterile swabs of cotton or other absorbent
material. The type of swab used depends on the part of the body affected. For
example, collection of a nasopharyngeal specimen requires a cotton-tipped
swab.
After the specimen has been collected, the swab is immediately placed in
a sterile tube containing a transport medium. Swab specimens are usually collected to identify pathogens and sometimes to identify asymptomatic carriers
of certain easily transmitted disease organisms.
58
-
Throat swab. Alternative names - Throat culture and sensitivity; Culture
throat.
59
Throat swab is a laboratory test done to isolate and identify organisms
that may cause infection in the throat. The test is used to establish the
diagnosis of bacterial infection with R-haemolytic streptococci (especially
Group A (Streptococcus pyogenes), Group С or Group G) and Arcanobacterium
haemolyticum. A throat swab is required to diagnose suspected Vincent's
angina and gonococcal pharyngitis or herpes simplex infection and to confirm
a clinical diagnosis of diphtheria. Viral detection culture is seldom indicated to
determine other viral causes of pharyngitis, but can be used to establish a
diagnosis of influenza. Influenza virus antigen gives a more rapid result.
Note. Patient must not use antiseptic mouthwashes before the test.
Implementation
- Explain the procedure to the patient to ease his anxiety and ensure
cooperation.
- Instruct the patient to sit erect at the edge of the bed or in a chair,
facing you.
- Wash your hands and put on gloves.
- Ask the patient to tilt his head back. Depress his tongue with the
tongue blade, and illuminate his throat with the penlight to check for inflamed
areas and tell him to breathe deeply.
- Using the cotton-tipped swab, wipe the
tonsillar areas from side to side,
including any inflamed or purulent sites
(Fig.26).
- Make sure you don't touch the tongue,
cheeks, or teeth with the swab to avoid
contaminating it with oral bacteria. Do
not touch oral mucosa or tongue with
swab.
Fig. 26. Collection of a throat swab
- Withdraw
the
swab
and
immediately place it in the culture tube. If you're using a commercial kit, crush
the ampule of culture medium at the bottom of the tube, and then push the
swab into the medium to keep the swab moist.
- Remove and discard your gloves, and wash your hands.
- Label the specimen with the patient's name and room number, the
physician's name, and the date, time, and site of collection.
- On the laboratory request form, indicate whether any organism is
strongly suspected, especially Corynebacterium diphtheriae (requires two
swabs and special growth medium), Bordetella pertussis (requires a
nasopharyngeal culture and special growth medium), and Neisseria
meningitidis (requires enriched selective media).
Place in a laboratory biohazard transport bag and send the specimen to
the laboratory immediately to prevent growth or deterioration of microbes.
60
Nose Swab
Implementation
- Explain the procedure to the patient
- Have the patient sit erect at the edge of the bed or in a chair, facing
you. Then wash your hands and put on gloves.
- Ask the patient to blow his nose to clear his nasal passages. Then
check his nostrils for patency with a penlight.
- Tell the patient to occlude one nostril first and then the other as he
exhales. Listen for the more patent nostril because you'll insert the swab
through it.
- While it's still in the package, bend the sterile swab in a curve and then
open
the
package
without
contaminating the swab.
- Ask the patient to tilt his head
back, and gently pass the swab through
the more patent nostril keeping the
swab near the septum and floor of the
nose. Rotate the swab gently and
remove it (Fig. 27).
Remove the cap from the
Fig. 27. Collection of a nose swab
culture tube, insert the swab, and break
off the contaminated end. Then close
the tube tightly.
- Remove and discard your gloves and wash your hands.
- Label the specimen for culture, complete a laboratory request form,
and send the specimen to the laboratory immediately in a laboratory
biohazard transport bag. If you're collecting a specimen to isolate a possible
virus, check with the laboratory for the recommended collection technique.
3.4. Basic types of enemas. Enema administration
"Enema is better than any purgative/laxative medicine"
Hippocrates
The term enema is used to refer to the process of instilling fluid through
the anal sphincter into the rectum and lower intestine for a therapeutic
purpose. Enemas can also be used to instill medications or nutrition. An
enema stimulates peristalsis via irritation of the colon/rectum and by causing
intestinal distention with fluid. Enemas are used to clean the lower bowel in
preparation for diagnostic or surgical procedures, to relieve distention and
promote expulsion of flatus, to lubricate the rectum and colon, and to soften
hardened stool for removal.
Enemas are generally discouraged for infants. They are given to children
in the same way as adults, although a smaller quantity of solution is used.
Disposable pediatric enemas are available in measured amounts and are much
safer than the enema bag. For a small child, a rubber-tipped bulb syringe also
may be used. Be careful not to use too much pressure when instilling the fluid.
Sometimes, the child will not be able to retain the solution. In this case, several
61
folds
of
toilet
tissue
or
a
piece
62
of
soft foam rubber may be held around the tube to help the child hold the
solution.The thickness of disposable diapers usually makes a bedpan
unnecessary. You may need to restrain a small child or ask for assistance.
An enema administration is performed using a flexible plastic rectal tube
with several large holes in the tip. This is connected to the tubing from a
solution bag or container. An enema can also be performed using a
prepackaged solution that comes in a soft plastic bottle with a pre-lubricated
rectal tip attached. Enema solutions are prepared using plain tap water or
saline, soapsuds solutions, oil solutions, or various medication solutions.
Precautions
Enemas should not be used as a first-line treatment for constipation.
Frequent use of enemas can lead to fluid overload, bowel irritation, and loss of
muscle tone of the bowel and anal sphincter. Never deliver more than three
consecutive enemas to treat a patient. A patient with diarrhea may not be able
to hold an enema. Enema administration must be used with caution in cardiac
patients who have arrhythmias. Insertion of the enema tube and solution can
stimulate the vagus nerve which may trigger an arrhythmia such as
bradycardia. Enemas should not be given to patients with undiagnosed
abdominal pain because the peristalsis of the bowel can cause an inflamed
appendix to rupture. Enemas should be used cautiously in patients who have
had recent surgery on the rectum, bowel. If the patient has rectal bleeding or
prolapse of rectal tissue from the rectal opening, cancel the enema and
consult with the physician before proceeding. Do not force the enema catheter
into the rectum against resistance. This can cause trauma to the rectal tissue.
Use only mild castile soap for soapsuds enemas because other soap
preparations are too harsh and irritate the rectal tissue.
Types of Enemas
The cleansing enema is probably the most common type of enema. It
may also be called a purgative enema. The purpose of this enema is to inject
enough fluid into the colon to soften feces, stimulate peristalsis, and produce
a bowel movement that empties the rectum and lower colon. This procedure
often is a necessary part of treatment when body functions are disturbed or
before surgery.
The temperature of water which will be used for newborns should be 30ЗГС, for infants before 6 mo - 27 - 28°C, from 6 mo to 1 year - 25-26°C, for
older ones - 22-24°C. Never use cold solutions. They could cause shock.
Standard cleansing enema volumes for pediatric patients are:
- for infants- gradually increases from30 up to 150(up to 250ml);
- for a toddler or preschooler - 250 to 500 ml;
- for a school-age child - 500 to 1000 ml;
- for an adult - 750 to 1000 ml.
A tap water or soapsuds enema dilates the bowel, stimulates peristalsis,
and lubricates the stool to encourge a bowel movement. These types of
enemas are instilled and held for 5 to 10 min, as tolerated. They are used to
treat constipation, to cleanse the bowel before a bowel exam, and to cleanse
the bowel before bowel surgery.
Hypertonic enema solutions can be used to pull excessive potassium or
ammonia from the bloodstream through the rectal wall. These substances are
63
then eliminated with the stool. 1 tsp of table salt is dissolved in 1 liter (1000
cc) of water to make the correct concentration. The enema is then delivered
through a soft rubber tube that can be inserted easily into the child's rectum.
Emollient Enema. An emollient enema consists of a small amount of olive
or cotton seed oil, given to protect or soothe the mucous membrane of the
colon. This enema is to be retained.
The oil retention enema is prepared in a smaller volume and is retained
in the bowel for 30-60 min. The purpose of the oil retention enema is to
soften the hardened stool and allow normal elimination. Sometimes, if an oil
solution has not been effective after several hours, it is necessary to follow
with an enema of saline solution. The temperature of the solution must not
exceed 38-39° С
Medicated Enema.The medicated enema, in which a drug is inserted into
the rectum, is sometimes the only way to give a patient a drug. It may also be
the best way to make a drug take effect quickly. Some drugs are rapidly
absorbed by the mucous membranes. The drug is combined with a small
amount of oil or saline to reduce its irritating effect on the mucous
membranes and to lessen the desire to expel it, because it is given to be
retained. Medicated enemas, such as antibiotic or anti-inflammatory
solutions, may need to be repeated daily over a period of a week or more for
full therapeutic effect. Steroid enema solutions can be administered to
alleviate bowel inflammation in patients with ulcerative colitis. Antibiotic
enema solutions can be administered to treat localized bacterial infections.
A tap water or soapsuds enema dilates the bowel, stimulates peristalsis,
and lubricates the stool to encourage a bowel movement. These types of
enemas are instilled and held for 5 to 10 min, as tolerated. They are used to
treat constipation, to cleanse the bowel before a bowel exam, and to cleanse
the bowel before bowel surgery.
Enema administration
- Check the physician's order and assess the patient's condition.
- Explain the procedure. If you're administering an enema to a child,
familiarize him with the equipment and allow a parent or another relative to
remain with him during the procedure to provide reassurance. Instruct the
patient to breathe through his mouth to relax the anal sphincter, which will
facilitate catheter insertion. Place a waterproof pad under the patient's hips to
protect the bedding and drape a sheet over the patient covering the entire
body except the buttocks. Place a bedpan and toilet paper within quick access
- Wash hands thoroughly and put on gloves.
- Assist the patient into the left-lateral Sims' position. It is performed by
having a patient lie on their left side, left leg extended and right leg flexed. Lift
the upper buttock so that the rectal opening can be visualized
- Place the lubricated tip of the clyster or catheter at the anal opening,
and gently advance the catheter through the anal sphincter into the rectum
toward the umbilicus (navel),7.5-10 cm for an adult.
When giving fluid through an enema bag, start with the bag suspended
from an IV pole at the patient's hip level. As the tubing is opened, slowly raise
the IV pole to promote fluid flow until the bag is 30.5 cm above 64
the hip for an
adult. Continue to hold the rectal tube in place throughout the procedure or it
will be expelled from the rectum. If the fluid will not flow in, gently rotate the
tubing within the rectum to clear the holes of the tubing from the wall of the
bowel or the impacted stool that may be occluding the flow. If ordered to give
a high enema, slowly raise the bag no more than 46 cm above the adult
patient's hip 30.5 cm above a child's hip and 15 cm above an infant's hip. This
will increase the water pressure to deliver the fluid higher into the bowel. When
all of the solution has been administered, clamp the tubing, remove the enema
catheter, and release the buttock.
- Send specimens to the laboratory if ordered.
- Rinse the bedpan or commode with cold water, and then wash it in hot
soapy water.
- Discard your gloves and wash your hands.
- Air the room if necessary.
Pediatric variations:
- The child may be too young to understand why an enema is being
administered, which may cause increased anxiety on the child's part.
- Have a parent administer the enema if reasonable, or have the parent
present to comfort the child and facilitate cooperation.
- Care must be taken to ensure that the temperature of the solution is
maintained to prevent damaging the child or make the child uncomfortable.
- It is important that the enema nozzle be well lubricated and that it is
inserted only 5 cm in children and 2.5 cm in infants.
- Be aware of the volumes required for different body sizes in infants
and children.
- Only isotonic solutions should be used in infants and children.
- Children who are not toilet trained will not be able to retain the enema
solution. Give the enema on an absorbent pad or while the child is on the
bedpan.
Administering an enema to a small infant
1. Prepare the solution (usually a weak soapsuds solution or tap water) in
a bowl, and fill the syringe by squeezing the bulb, putting the tip in the water,
and then releasing the pressure on the bulb, allowing it to fill.
2. Lubricate the rectal tip generously.
3. Have the baby lay on his or her back on the bed with a diaper
underneath, or across your knee, whichever seems easier.
4. Using your forefinger lubricate the baby's anal area to make insertion
easier.
5. Slowly insert the rectal tip into the rectum. Rotating the tip back and
forth
makes
it
slip
in
easier.
65
6. Gently, but firmly, squeeze the bulb, causing the solution to be
introduced into the rectum.
7. When all the solution has been introduced, slowly remove the rectal
tip, taking care not to release pressure on the bulb.
8. Clamp the buttocks together for a few minutes to encourage retention
of the solution.
9. Allow the baby to expel the enema onto the diaper.
10. Occasionally, especially if the baby is constipated, no solution will be
expelled.This is no cause for alarm. It means that the dried, hardened stool
has absorbed all the solution. Simply wait a while and repeat the enema.
Infants should lie on supine position with lifted
legs. Enema Bulb syringes are used for small
volume enemas (Fig. 28). They are used to fill only
the lower colon with water or other enema solutions. The bulb syringe is filled by squeezing the
air out of the bulb, placing the tip of the bulb
which creates suction to fill the bulb syringe with
the bulb syringe into the water or solution, and
releasing the liquid.
Fig.28. Giving an enema
After the tip is gently inserted into the
rectum the filled bulb syringe is squeezed gently to empty the solution into
the lower colon. Bulb syringes are used to relieve constipation in adults,
children and infants.
Aftercare
After administering an enema, remain near the patient in case he or she
needs assistance with the bedpan or to get to the bathroom. Medicated
enemas that are expelled immediately may need to be repeated, using fresh
solution. Follow the directions or consult with the physician. Place disposable
items, gauze pads, and gloves in a trash bag, then seal and discard it. Assist
the patient to the bathroom or with the bedpan after he or she has held the
enema solution for the correct amount of time. Hands should be washed after
performing the procedure. Note the results of the enema.
Documentation
Record the date and time of enema administration: type and amount of
solution; retention time; approximate amount returned; color, consistency,
and amount (minimal, moderate, or generous) and foreign matter, such as
blood, rectal tissue, worms, pus, mucus, or other unusual abnormalities
within the return; any complications that occurred; and the patient's tolerance
of the treatment.
Complications of enemas administration can include:
- dizziness or faintness;
- excessive irritation;
- swelling;
- hyponatremia or hypokalemia from repeated administration of
hypotonic solutions;
- cardiac arrhythmias resulting from vasovagal reflex stimulation after
insertion
of
the
rectal
catheter;
67
- bleeding or prolapse of the rectal tissue (rare).
If any of these symptoms are apparent, or if the patient complains of pain
or burning during enema instillation, stop the procedure and notify the
physician.
3.5 .Technique of application of mustard plasters.
Application of a hot and cold compresses
Mustard plaster (synonyms: Sinapism, mustard poultice), is a medicinal
plaster made with a paste-like mixture of powdered black mustard, flour, and
water, used especially as a counterirritant. Also called sinapism.
These plasters are used as a decongestant in common respiratory
infection (colds, coughs, simple bronchitis) for the purpose of making
counterirritation.
Technique of application of mustard plasters
According to the prescription of the doctor, mustard plasters are put on
the certain sites of the chest; the technique is as followed:
At first it is necessary to examine skin attentively as mustard plasters are
stuck only on the healthy skin.
Flannel cloth or gauze in 3-4 layers (the size should be 2 cm wider and
longer than used mustard plasters) is soaked in some pasteurized sunflower
oil, squeezed out and placed on a necessary site of the thorax.
Soak the mustard plaster into hot water (45- 50°C) for a few moments.
Place it on the area to be treated (avoiding the heart area). Keep it in position
using a dry towel. Several plasters can be placed side by side. More often 2
mustard plasters (the size depending on the age of the child) are put on the back, on
the lower sites of the chest on both sides.
Leave to work according to the patient's tolerance, until the skin reddens
and a sensation of heat is felt (8 to 15 min maximum). Treatment should be
discontinued if the sensation of heat becomes too intense.
Remove the plaster once revulsion has been obtained. During some
hours after the procedure the child should be well covered.
Like any active substance, in certain persons this medicine can produce
side effects. Mustard plasters can cause local irritation, burns and allergic
reaction. However, reddened skin at the point of application is normal.
Heat Application
Heat applied directly to the patient's body raises tissue temperature and
enhances the inflammatory process by causing vasodilation and increasing
local circulation. Heat also increases tissue metabolism, reduces pain caused
by muscle spasm, and decreases congestion in deep visceral organs, makes
the chilly patient more comfortable.
Direct heat may be dry or moist. Dry heat can be delivered at a higher
temperature and for a longer time. Common methods for applying dry heat
are an electric pad, warm-water bag, aquathermic pad, heat lamp, or electric.
Moist heat softens crusts and exudates, penetrates deeper than dry heat,
doesn't dry the skin, produces less perspiration, and usually is more
comfortable for the patient. Devices for applying moist heat include
warm
68
compresses for small body areas and warm packs for large areas. Moist, hot
applications heat skin more quickly and are more penetrating than
applications of dry heat because water is a better heat conductor than air. Both
dry and moist heat are usually applied for their local effects.
Direct heat treatment can't be used on a patient at risk for hemorrhage.
It also is contraindicated if the patient has a sprained limb in the acute stage
(because vasodilation would increase pain and swelling) or if he has a
condition associated with acute inflammation, such as appendicitis. Direct
heat should be applied cautiously to pediatric and elderly patients and to
patients with impaired renal, cardiac, or respiratory function. It should be
applied with extreme caution to heat-sensitive areas, such as scar tissue and
stomas.
Implementation
- Check the physician's order, and assess the patient's condition.
- Explain the procedure to the patient, and tell him not to lean or lie
directly on the heating device because this reduces air space and increases the
risk of burns. Warn him against adjusting the temperature of the heating
device or adding hot water to a hot-water bottle. Advise him to report pain
immediately and to remove the device if necessary.
- Provide privacy and make sure the room is warm and free of drafts.
Wash your hands.
- Take the patient's temperature, pulse, and respiration to serve as a
baseline. If heat treatment is being applied to raise the patient's body
temperature, monitor temperature, pulse, and respirations throughout the
application. Position him comfortably in bed.
- Expose only the treatment area because vasodilation will make the
patient feel chilly.
Applying a hot-water bottle, an electric heating pad, an aquathermia
pad, or a chemical hot pack
- Fill the bottle with hot tap water to detect leaks and warm the bottle;
then empty it. Run hot tap water into a pitcher and measure the water
temperature with the bath thermometer. Adjust the temperature to 40.6 to
45.0° С - for children under age 2 and to45.1 to-50.0°C - for adults.
- Next, pour hot water into the bottle, filling it one-half to two-thirds
full. Partially filling the bottle keeps it lightweight and flexible to mold to the
treatment area. Squeeze the bottle until the water reaches the neck to expel
any air that would make the bottle inflexible and reduce heat conduction.
Fasten the top and cover the bag with an absorbent cloth. Secure the cover
with tape or roller gauze.
- Before applying the heating device, press it against your inner
forearm to test its temperature and heat distribution. If it heats unevenly,
obtain a new device.
- Apply the device to the treatment area and, if necessary, secure it with
tape or roller gauze. Begin timing the application.
- Assess the patient's skin condition frequently, and remove the device
if you observe increased swelling or excessive redness, blistering, maceration,
69
or pallor or if the patient reports discomfort. Refill the hot-water bottle as
necessary to maintain the correct temperature.
- Remove the device after 20 to 30 min, or as ordered.
N.B! Tissue exposed to heat for more than 30 minutes begins to develop
vasoconstriction.
Dry the patient's skin with a towel and redress the site, if necessary.
Applying a warm compress or pack
- Place a linen-saver pad under the site.
- Remove the warm compress or pack from the bowl or basin. (Use
sterile forceps throughout the procedure if necessary.)
- Wring excess solution from the compress or pack (using sterile
forceps if needed). Excess moisture increases the risk of burns.
- Apply the compress gently to the affected site (using forceps, if
warranted). After a few seconds, lift the compress and check the skin for
excessive redness, maceration, or blistering. When you are sure the compress
is not causing a burn, mold it firmly to the skin to keep air out, which reduces
the temperature and effectiveness of the compress. Work quickly so the
compress retains its heat.
- Apply a waterproof covering (sterile, if necessary) to the compress.
Secure it with tape or roller gauze to prevent it from slipping.
- Place a hot-water bottle, aquathermia pad, or chemical hot pack over
the compress and waterproof covering to maintain the correct temperature.
Begin timing the application.
- Check the patient's skin every 5 min for tissue tolerance. Remove the
device if the skin shows excessive redness, maceration, or blistering or if the
patient experiences pain or discomfort. Change the compress as needed to
maintain the correct temperature.
- After 15 to 20 min or as ordered, remove the compress. Discard the
compress into a waterproof trash bag.
- Dry the patient's skin with a towel (sterile, if necessary). Note the
condition of the skin and re-dress the area, if necessary. Take the patient's
temperature, pulse, and respiration for comparison with baseline. Then make
sure the patient is comfortable.
If you use an electric heating pad
Check the cord for frayed or damaged insulation. Then plug in the pad
and adjust the control switch to the desired setting. Wrap the pad in a
protective cloth covering, and secure the cover with tape or roller gauze.
If you use a chemical hot pack
Select a pack of the correct size. Then follow the manufacturer's directions (strike, squeeze, or knead) to activate the heat-producing chemicals.
Place the pack in a protective cloth covering, and secure the cover with tape or
roller gauze.
If you use an aquathermia pad
Check the cord for safety, as above, and fill the control unit 2/3 full with
distilled water. Don't use tap water because it leaves mineral deposits
in the
70
unit. Check for leaks, and then tilt the unit in several directions to clear the
pad's tubing of air. Tighten the cap, and then loosen it a quarter turn to allow
heat expansion within the unit. After making sure the hoses between the
control unit and the pad are free of tangles, place the unit on the bedside
table, slightly above the patient so that gravity can assist water flow. If the
central supply department hasn't preset the temperature, use the
temperature-adjustment key provided to set the temperature on the control
unit. The usual temperature is 41° C. Then place the pad in a protective cloth
covering and secure the cover with tape or roller gauze. Plug in the unit, turn it
on, and allow the pad to warm for 2 min.
Complications
Because tissue damage may result from direct heat application, monitor
the temperature of the compress carefully. Assess frequently the condition of
the patient's skin under the heat application device.
Documentation
Record the time and date of heat application: type, temperature or heat
setting, duration, and site of application; patient's vital signs, and skin
condition before, during, and after treatment; signs of complications; and the
patient's tolerance of treatment.
Cold application
The application of cold constricts blood vessels, inhibits local circulation,
suppuration, and tissue metabolism; relieves vascular congestion; slows
bacterial activity in infections; reduces body temperature; and may act as a
temporary anesthetic during brief, painful procedures. Because treatment with
cold also relieves inflammation, reduces edema, and slows bleeding, it may
provide effective initial treatment after eye injuries, strains, sprains, bruises,
muscle spasms, and burns. Cold doesn't reduce existing edema, however,
because it inhibits reab- sorption of excess fluid.
Cold may be applied-in dry or moist forms, but ice shouldn't be placed
directly on a patient's skin because it may further damage tissue. Moist
application is more penetrating than dry because moisture facilitates
conduction.
Devices for applying cold include:
an ice bag or collar, aquathermia pad (which can produce cold or heat),
chemical cold packs, ice packs.
Devices for applying moist cold include:
- cold compresses for small body areas;
- cold packs for large areas.
Apply cold treatments cautiously on patients with impaired circulation,
on children, and on elderly or arthritic patients because of the risk of ischemic
tissue damage. Cold applications are useful right after an injury.
71
Special considerations
- Apply cold immediately after an injury to minimize edema.
- Although colder temperatures can be tolerated for a longer time
when the treatment site is small, don't continue any application for longer
than 1 h to avoid reflex vasodilation. The application of temperatures below
15° С also causes local reflex vasodilation.
- Use sterile technique when applying cold to an open wound or to a
lesion that may open during treatment. Also maintain sterile technique during
eye treatment, with separate sterile equipment for each eye to prevent crosscontamination.
- If the patient is unconscious, anesthetized, neurologically impaired,
irrational, or otherwise insensitive to cold, stay with him throughout the
treatment, and check the application site frequently for complications.
- Avoid direct and prolonged ice contact with the skin, to avoid
damaging it, by placing a cloth between the cold source and the skin.
pack
Applying an Icecap or Ice Collar, an aquathermia pad, or a chemical cold
1. Wash your hands.
2. Select a device of the correct size, fill it with cold tap water, and check
for leaks.
3. Fill an icecap or collar about 3/4 full with crushed ice. (Small pieces of
ice cool faster because they have more surface area.) Sometimes cold water is
added to increase the cooling effect further.
4. Squeeze the device to expel air that might reduce conduction. (A flat
icecap or ice collar is easier to fit to the body).
5. Screw in the top or fold over the end, making sure that the top is
firmly in place.
6. Dry the icecap or collar and cover with a towel. (The protective cover
prevents tissue trauma and absorbs condensation).
7. Adjust bag on the part of body to be treated.
8. Leave icecap or ice collar in place for 30 min to 1 h, as directed. Keep
icecap or ice collar off for 1 h before reapplying it, unless directed otherwise.
(Prolonged applications of cold could dangerously slow circulation and may
cause tissue damage. The ice will melt in this length of time as well).
9. Wash your hands after applying the icecap or ice collar and after
removing it.
10. Document the treatment on the patient's chart, noting "on" and "off"
periods and patient's reactions.
Applying a cold compress or pack
1.
Cool a container of tap water by placing it in a basin of ice or by
adding ice to the water. Using a bath thermometer for guidance, adjust the
water temperature to 15° С or as ordered.
2.
Immerse the compress or pack material in the water. Place a linensaver pad under the site.
57
3.
Remove the compress or pack from the water, and wring it out to
prevent dripping. Apply it to the treatment site, and begin timing the
application.
4.
Cover the compress or pack with a waterproof covering to provide
insulation and to keep the surrounding area dry. Secure the covering with tape
or roller gauze to prevent it from slipping.
5.
Check the application site frequently for signs of tissue intolerance,
and note complaints of burning or numbness. If these symptoms develop,
discontinue treatment and notify the physician.
6.
Change the compress or pack as needed to maintain the correct
temperature. Remove it after the prescribed treatment period (usually20 min).
Complications
-Hemoconcentration may cause thrombi.
-Intense cold may cause pain, burning, or numbness.
3.6. Technique of gastric lavage
Gastric lavage, also commonly called Gastric suction; Stomach pumping;
Nasogastric tube suction, is the process of mechanical cleaning out the
contents of the stomach.
This test may be performed for several different reasons, including:
- Removing poisons, toxic materials, or overdosed medications from
the stomach.
- Cleaning the stomach prior to an upper endoscopy in someone who
has been vomiting blood.
- Collecting stomach acid for tests.
- Providing relief and decompression in someone with intestinal
blockage.
Alternatives
An alternative for gastric lavage is the oral administration of activated
carbon, a form of carbon with a large surface area for binding poisons,
preventing absorption by the gastrointestinal tract.
Technique
Gastric lavage involves the passage of a tube via the mouth or nose down
into the stomach, followed by sequential administration and removal of small
volumes of liquid.
On draining the stomach in connection with poisoning of the child it is
necessary to put the patient on the left side (on the right side position washing
waters will flow into duodenum).
To perform gastric lavage a glass funnel is attached to the end of the
rubber tube. Water, Ringer solution or some other lavaging solution (as
prescribed by the doctor) is poured into the elevated funnel, and the liquid
passes into the stomach. When the funnel is held beneath the level of the
child's head (he is placed on his side on a table, buttocks elevated) the
stomach contents pour out together with the lavaging liquid. When the
stomach has been emp* 4 -t^.- ' «Ш
73
tied the funnel is again elevated and a new portion of the liquid poured in. This
procedure is repeated several times until the fluid emerging from the stomach
becomes clear. At the end of the lavaging procedure 50 to 100 ml of solution
are left in the stomach. In domestic conditions gastric lavage is performed by
giving the child an abundant amount of warm water to drink (1-2 litres), until
vomiting is evoked. This procedure may only be employed if the child is
conscious. According to the doctor's prescription the waters obtained are sent
to the laboratory for the analysis. After lavage, the child is generally kept for 1
or 2 h before being discharged, unless much of the poison was absorbed into
the bloodstream.
Complications include:
1. Nasal irritation, sinusitis, epistaxis, rhinorrhea, skin erosion or
esophagotracheal fistula secondary to NG placement.
2. Aspiration pneumonia secondary to vomiting and aspiration.
3. Hypoxia, cyanosis, or respiratory arrest due to accidental tracheal
intubation.
4. Laryngospasm, bradycardia, hyponatremia, water intoxication, or
mechanical injury to the stomach.
Documentation
Record the date and time of lavage, the size and type of NG tube used,
the volume and type of irrigant, and the amount of drained gastric contents.
Document this information on the intake and output record sheet, and include
your observations, including the color and consistency of drainage. Also keep
precise records of the patient's vital signs and LOC, any drugs instilled
through the tube, the time the tube was removed, and how well the patient
tolerated the procedure.
3.7. Inserting the flatus tube
The flatus tube is reusable rubber tube used for the expelling of flatus
(gas) from the intestine. It is also used for the treatment of sigmoid volvulus
and intussusceptions. It is used also for barium enema. Inserted in the rectum,
the device provides an outlet for accumulated gas and relieves the discomfort
of intestinal distention.
Equipment: rectal tube, lubricant, disposable gloves.
Procedure
1. Ask the patient to lie on his or her side (preferably the left).
2. Wash hands and put on gloves.
3. Lubricate the tube.
4. Insert the tube 7.5-10 cm into the rectum. The tube is inserted far
enough to pass any stool in the lower rectum and reach the gas above the stool.
5. Determine the patency of the tube. If the tube is patent, gas or feces
will return. The tube can become plugged with stool; it must be kept open.
6. Leave the tube in the rectum from 20 to 30 min. After that time the
sphincter muscles become numbed and the tube ceases to stimulate peristalsis.
7. After use, rinse a tube with running water and wash with soap and
water. It can be sterilized by boiling or autoclaving.
8. Properly dispose of your gloves and wash your hands.
74
9. Document the result on the patient's chart; the duration of the
insertion, the amount of gas and feces expelled, if any, and whether the
patient felt relief.
Tests for self-training
Q1. The water temperature for a cleansing enema for children at the
senior age should be:
A. 30-32°C.
B. 26-26.5 °C.
C. 34-36.6°C.
D. 17-18°C.
E. 20-22°C.
Q2. The site for put on mustard plasters should be:
A. Forehead.
В Joints.
C. Left part of the chest.
D. Interscapular region.
E. Abdomen.
Q3.The normal leucocyte rate by Nechiporenko test is:
A. 2,000.
B. 4,000.
C. 5,000.
D. 8,000.
Q4.The indication for introducing a flatus tube is:
A. Gastrointestinal bleeding;
B.A fissure of the anus;
C. Endoscopic examination of the rectum;
D. Meteorism;
E. An inflammatory process of the large intestine.
Q5.The length of tube for gastric lavage for a child is measured:
A. From a nasal bridge to the xiphoid process.
B. From a tragus to the xiphoid process.
C. From a nasal bridge to an ear-lobe and to the xiphoid process.
D.From a nasal bridge to tragus and to the navel.
E. From a chin to the navel.
Q6. For the detection of enterobiasis, it is necessary to study:
A. A rectal ampulla smear.
B. A scrape from perianal folds and from walls of the lower rectum.
C. A scrape from walls of the lower rectum only.
D.
The whole portion of excretion.
E. Gastric contents during the implementation of a cleansing enema.
Q7. What should be the optimal body position for a cleansing enema of
an infant?
A. On the left side.
B. On the right side.
C. Supine position with raised legs. D. Prone position. Q8. Which one of
the following statements about microscopic hematuria is correct?
A. When it is found on urinary dipstick, no further examination is
warranted.
B. It is clinically significant only when 30 or more red blood cells per
high- power field are visible.
C. It is clinically significant when three or more red blood cells per highpower field are visible on one urine sample.
D. It is clinically significant when three or more red blood cells per highpower field are visible on two out of three properly collected urine samples.
75
E. It is a uniformly benign finding that can safely be ignored.
Q9. The volume of water needed for implementation of cleansing enema
to infant makes:
A. 150 ml-200ml.
B. up to 50 ml.
C. 60-150 ml.
D. 200 ml-300ml.
E. no more than 10 ml for each month of child's life.
Q10. Nechiporenko test is the assessment of:
A. Daily diuresis.
B.Amount of formed elements.
C. Presence of acetone and bile pigments.
D.Density.
E. Presence of salts.
Correct answers: Q1 -E; Q2 -D; Q3- A; Q4 -D; Q5-C; Q6 -B; Q7- C; Q8D; Q 9 - C; Q10 - В
CHAPTER 4.
THE BASIC DUTIES OF A NURSE OF MANIPULATION ROOM OF CHILDREN'S
DEPARTMENT
4.1 The basic duties of a nurse of manipulation room:
1. To do all doctor's prescriptions and manipulations (injections on
doctor's orders).
2. Blood sampling for biochemical, serological and other investigations.
3. To help the doctor to carry out doctor's manipulations (blood
transfusion, skin test, etc.).
4. To follow all instructions of aseptics and antiseptics while doing all
manipulations.
5. To follow all instructions for preventing injection complications,
anaphylactic shock, etc.
6. To store in good order medical equipment, instruments; to provide
with sterile dressings, medicines, dropping glasses (bottles) and syringes.
7. To store medicines of group "A" and "B" in a special safe, to take their
stock.
8. With the help of a senior nurse to order medicines, instruments, etc.
9. To provide the proper sanitary and antiepidemic regimen.
Ю.То improve professional qualification regularly.
The equipment of manipulation rooms includes:
- a table for documents;
- a couch;
- a working table for sterile dressing storage, ethyl alcohol, tweezers,
tourniquets, tray sets;
- metal medical safes with glass walls for storing medicines. These
medicines are used for urgent and current care;
- a refrigerator (for serum store, sets for blood groups identification,
stands with clean test-tubes for blood collection);
- supports for infusion;
- a bactericidal lamp.
76
4.2. Introduction of medicinal agents into children
Drugs may be administered by many routes. The topical, or dermatomucosal route includes aural, ocular, nasal, and vaginal administration,
oropharyngeal inhalation and transdermal absorption.
The enteral route, the most commonly used one, involves drug absorption
through the Gl tract. This can include oral, sublingual, buccal, feeding tube, or
rectal administration.
The parenteral route includes intradermal, subcutaneous, I.M., I.V.,
intrathecal (into the spinal canal), and intraosseous infusions or injections.
The endotracheal route involves administering a drug into the respiratory
system through an endotracheal tube. The epidural route involves giving a
drug (usually an anesthetic or an opioid analgesic) through a catheter inserted
near the spinal cord by a lumbar puncture. The intrapleural route involves
injecting a drug through the chest wall into the pleural space.
More than any other factor, the administration route determines the
onset of a drug's effect. For example, drugs administered I.V. act almost
instantly because they're immediately available in the bloodstream.
Antibiotics, for instance, are commonly given I.V. to provoke a quick,
continuous response. Other drugs must be given I.V. because they're
ineffective, or even dangerous, when given by other routes.
Drugs administered intrathecally, such as spinal anesthetics, also act
rapidly. Drugs administered orally must be absorbed into the bloodstream
before they can take effect.
Before administering any medication the following items should be
remembered:
- The medication will always be taken at a fixed time and for the
required duration. Always complete the treatment.
- Always check that the medication is correct.
- Check there are no signs of any damage (a broken container, a bad
appearance, etc.) and that the expiry date has not been reached.
- Check the "Medication counter indications, side effects and
interactions" listing.
If the medication is to be administered several times a day, try to adjust
the hours so as to respect the patient's rest. Immediately after administering
the medication, put down the date, hour, quantity, and route of
administration.
When medication is administered, certain safely rules, called «Seven
Rights», must be followed:
1. Right patient 2. Right drug 3. Right dose 4. Right time
5. Right route 6. Right technique
7. Right documentation
77
Parenteral administration
Injection is a method of introducing liquid drugs into
the tissue through a needle. The injection may beintradermal,
subcutaneous, intramuscular: or intravenous. When an intravenous route is used, the method is usually known as an
infusion. (Other routes such as intracardiac, intramedullar,
intrathecal, intraosseous, and intraperitoneal are used only
by physicians or specially trained nurses). The parenteral
routes commonly used by nurses, are presented in detail
information on general principles and preparation of
medication.
General principles of parenteral administration
Injections are given in various ways, but the basics discussed here apply
to every method.
A drug may be administered by injection for the following reasons:
- the drug is most effective when given by this route or is unavailable in
any other route;
- the desired action is needed quickly;
- it is necessary to ascertain the accuracy of the dose of drug injected or
retained;
- the patient is nauseated or vomiting;
- the patient's mental or physical condition renders him or her unable to
swallow oral medication;
- the drug cannot be absorbed by way of the digestive system.
Injected drugs are absorbed faster than those administered orally, and
they are absorbed even more quickly as the routes move from the tissues to
the bloodstream. The faster method is generally the intravenous one, with the
exception of intracardiac injection (directly into the heart), which is used in
emergencies and administered by a physician.
An injection may be momentarily painful when the needle pierces the
skin because pain receptors are located there. Deeper insertion of the needle
does not mean greater pain. Injecting the solution fairly slowly distributes it
more evenly in the tissues and prevents painful pressure. The needle should
be inserted and removed quickly, however. Gently massaging the area after the
needle is withdrawn speeds absorption and helps relieve discomfort.
The nurse should not be afraid to give an injection, but it is important to
realize that possible dangers do exist. The injection may enter a blood vessel,
in which case the drug could be absorbed too rapidly and cause damage.
Paralysis or nerve damage, as well as scar formation, necrosis, and sloughing
of the tissues, embolism, and abscess or cyst formation may also result.
Syringes
Measurements are stamped on the barrel of the syringe (Fig. 29).
Milliliters are subdivided into tenths. A subcutaneous or intramuscular
injection is usually given with a 2- to 3-ml syringe. Special syringes are used
for tuberculin and other intradermal skin tests and for insulin injections.
78
Hunger
Barrel Tip
\ 1 Y SK
Fig. 29. Parts of needle and syringe
Syringes are disposable. In one type, the entire unit is discarded after
one use. In another type, the medication is premeasured in a disposable
cartridge- needle unit that is damped in a nondisposable holder. Disposable
systems are used to prevent cross-contamination. Do not touch the inside or
the tip of the barrel or the shaft of the needle. Touching any of these areas
could contaminate the injection setup and could cause an infection in the
patient)
Needleless systems are available for use with an I.V. setup.This syringe
has a plastic tip which can be inserted into a special port.
The safely syringe is becoming more popular. It has a plastic sheath which
is pulled down after a medication is drawn up, to protect the needle. After the
injection has been given, this sheath is pulled out, twisted and locked into
place. This precludes recapping needles and prevents needle sticks to nurses
and other personnel.
An insulin syringe. Insulin, a drug used to control diabetes mellitus, must
be given subcutaneously; it cannot be given by mouth because digestive enzymes destroy it. The physician prescribes the dosage, according to the needs
of the patient, and adjusts it if necessary.
An insulin syringe has four parts: a cap, a needle, a barrel, and a plunger.
• The needle is short and thin and covered with a fine layer of silicone to
allow it to pass through the skin easily. A cap covers and protects the needle
before it is used.
The barrel is the long, thin chamber that holds the insulin. The
barrel is marked with lines to measure the number of insulin units.
The plunger is a long, thin rod that fits snugly inside the barrel of the syringe. It easily slides up and down to push the insulin out through the needle.
The plunger has a rubber seal on the end that is inside the barrel, to prevent
leakage. To measure the required amount of insulin, you move the rubber seal
until it matches the correct line on the barrel.
Insulin syringes are made in several sizes (Table 4).
Some people inject the insulin with a syringe that delivers insulin just
under the skin. Others use insulin pens, jet injectors, or insulin pumps.
79
Syringe size and insulin units
Table 4
Syringe size, ml
Number of units the syringe holds
1/4 or 0,25
25
1/3 or 0,33
30
1/2 or 0,50
50
Insulin pens look like pens with cartridges - but the cartridges are filled
with insulin. They can be used instead of needles for giving insulin injections.
Some pens use replaceable cartridges of insulin; other models are totally
disposable after the pre-filled cartridge is empty. A fine short needle, like the
needle on an insulin syringe, is on the tip of the pen. Users turn a dial to select
the desired dose of insulin and press a plunger on the end to deliver the
insulin just under the skin (Fig. 30).
See
below
instruction
for
using
Insulin
pens.
1 .Remove protective
tub
4. Never click the
needle on at an angle
2. Click the needle 3. Hold the needle on the
table and click the pen
with the outer
into the needle
needles shield still
on, straight onto the
pen
5. Remove the outer
needles shield and
keep safe
6. Remove the
inner needle shield
^■HHHHHHMhK jh7.
Patient should insert the
needle and slowly
inject the insulin
_____ ■
шшшшя
80
8. Carefully replace the
outer
needle
shield
Fig. 30. Instruction for using Insulin pens
9. Screw the needle
off and dispose of
carefully
81
Insulin Jet Injector may be an option for people
who do not want to use needles. These devices
use high pressure air to send a find spray of
insulin through the skin. Jet injectors have no
needles (Fig. 31).
An insulin pump is an external device that
continuously delivers rapid-acting insulin to patient's body through a tiny tube placed under the
skin. About the size of a cell phone, it can be
hidden under clothing or worn on a waistband.
The patient programs the pump to dispense the
necessary amount of insulin.
The insulin pump is a small electronic device
(worn externally) that continuously delivers
rapid-acting insulin subcutaneously. Insulin
pumps contain a 3 ml cartridge/syringe attached
to a thin, long (60-100 cm) tube with a needle or
Teflon catheter on the end (Fig. 32). The needle/
catheter is inserted into the subcutaneous tissue
usually in the abdomen and changed every 3
days. The pump is about the size of a pager and is
designed to closely mimic the functioning of a
normal pancreas.
It is worn in a pocket or on a belt. A key
benefit of an insulin pump is that it can help
people with diabetes gain tighter control of blood glucose levels without
increasing the risk of hypoglycaemia. This can provide both short and long
term health benefits as well as a more flexible lifestyle.
Tuberculin Syringes. Minims and milliliters may be identified on
tuberculin syringes. These syringes have a very small diameter and are marked
in fine gradations up to 1 ml. They are always clearly marked in tenths and may
be graduated in hundredths of a milliliter.
The needle
Needles are made of stainless steel and are disposable. The needle is
hollow (the lumen); the part attached to the syringe is called the hub or hilt
(see Fig. 29). The needle has a sharp point and a beveled (slanted) edge, so
that it can be inserted easily and with minimum discomfort to the patient.
Always inspect a needle before giving an injection to be sure that the point is
perfect; a dull or damaged needle should never be used. Be sure the needle is
firmly attached to the syringe.
The length and gauge of the needle chosen depend on the type of
medication given, the route, the site of injection, and the patient's weight.
Needle lengths vary from 1/2 inch to 5 inches. The gauge (diameter) of the
needle varies from 14 to 28. Smaller gauge numbers indicate larger outer
diameters. Inner diameter depends on both gauge and wall thickness. For
example, a tuberculin test is given with a short, fine needle about 1/2 to
3/4inches long, 25 gauge. An intramuscular injection is given with a larger
82
needle,
about
1
V,
to
2
inches
83
long.
The gauge depends on the viscosity (thickness) of the medication (20-22
gauge is usual). The length depends on the patient's size. The administration
of blood requires a larger gauge needle.
Note! Always inspect the needle before performing the injection. Do not
use the needle if the tip is bent, curved or you can see spurs. This rarely occurs
but should always be checked.
Preparing medications for administration by injection
Drugs that are given by injection are packaged in many ways. Some are
dispensed as powders because they would deteriorate in a solution. They are
diluted, immediately before use, with the solution (sterile water or normal
saline) suggested by the manufacturer. If the drug will remain stable in a
solution, it is dispensed in an ampule, a vial. There are single dose ampules
and single and multidose vials.
An ampule is a glass container that holds a single dose of medication. Because there is no way to prevent contamination of an open ampule, any unused
medication must be discarded. A vial is a glass container with a self-sealing
stopper. Because of this self-sealing stopper, vials can contain more than one
dose of a medication.
Drawing up medication from an ampule or vial
Step1. Wash hands.
Step 2.Gather equipment. Check any inconsistency with physician.
Step 3.Unlock medication card or drawer. Check expiration date on
medication.
AMPULE (Fig 33, st 4-7).
Step 4.Hold ampule upright. Use finger to tap on stem of ampule or hold
ampule by the stem and rotate hand in a circular motion. All medication in the
ampule should be in the lower part prior to snapping off the stem.
Step 5.Grasp the stem with alcohol swab or gauze pad. Pad protects the
nurse's finger from glass particles when stem is removed.
Step 6.Snap off neck of ampule away from your hands and face.
Step 7.Remove cap and insert needle into ampule. Certain agencies may
recommend use of a filter needle. Withdraw the medication. Avoid touching
rim of ampule with needle and injecting any air into ampule. Use one of the
following methods:
7a. Keeping ampule upright on a flat surface, insert needle into solution
and aspirate medication into syringe.
7b. Invert the ampule, insert needle into the solution and aspirate
medication into syringe. Keeping the needle in the solution prevents aspiration
of air. Touching the sterile needle against the ampule rim contaminates the
needle. There is no need to inject air into ampule because contents are not
under pressure.
Step 8.Remove needle from solution in ampule. Hold needle upright and
discard any air that has been with drawn into syringe. Discard any excess
medication into plastic cup or sink. Checking amount of medication withdrawn
from
84
ampule ensures that correct dose is administered)
Step 9.Change needle if necessary, recap the needle, or pull the safety
sheath over the needle. Do not lock the safety sheath. Cap maintains sterility
of needle.
Step 4. Tapping the stem of an ampule
Step 6. Snapping off the neck of
an ampule
Step
7a.
Keeping
an
Step 7b. Inverting an ampule to
when withdrawing medication
ampule
upright
withdraw medication
Fig. 33. Steps for drawing up medication from an ampule
Step 10.Discard used ampule in sharps container. Proper disposal
prevents accidental injury.
VIAL
Step 11. Remove metal or plastic cover from vial and cleanse the rubber port with alcohol swab. Cap and cleansing with alcohol swab decrease
the possibility of introducing contaminants irnto the vial.
Step12. Remove needle cap and add aimount equal to amount of
medication that will be drawn from vial.
Step 13.Insert needle through center of rubber stopper and inject air
into vial keeping the needle (Fig 34). Air should be injected into a space,
rather than bubbled through solution so accurate dose is withdrawn into
syringe.
Step 14.Invert the vial. Steady vial and syringe in nondominant hand at
eye level. Brace little finger against plunger. Holding vial and syringe
securely prevents contamination of the medication. The plunger is held in
case negative pressure already exists in the vial. This could force the
plunger out.
85
aspi-
Step 15.Move needle into solution. Medication rather than air will be
86
rated.
Step 16.Use dominant hand to pull back on plunger of syringe.
Withdraw accurate dose into syringe (Fig 34). Remove needle from vial.
Positive pressure in vial promotes easy aspiration of fluid into syringe.
Step 17.Hold needle upright and recheck syringe contents for presence of
air. Tap barrel of syringe to move air bubbles upward prior to expelling them.
Reinsert needle into solution if it is necessary to withdraw any additional medication. Removing air bubbles ensures that accurate amount of medication was
withdrawn.
Step 18.Change needle if necessary, recap the needle, or pull safety
sheath over needle. Do not lock. Cap maintains sterility of needle.
Step 19.Discard used single dose vial or store multidose vial according to
agency policy. Proper disposal prevents transmission of organisms.
Step 20.Wash hands.
Step 21.Always wear gloves when administering injections.
Administering an intradermal injection
An intradermal injection is a shallow injection, just beneath the epidermis
(Fig. 35). These injections are usually performed for diagnostic purposes. A
Step 13. Adding air to the vial
Step 16. Withdrawing medication
from a vial
Fig. 34. Steps for drawing up medication from a vial
tuberculin syringe with a 25- to 26-gauge needle is used.The inner aspect of
the lower arm is a common site for intradermal injections.
87
88
SUBCU
TANEO
US
«S-tie
gnee
aogie
iNTRA
OERM
AL
sOto
15ч)<
чг« ang *
1
INTRAMUSCULA
R
Ep*}e
nn«
Dem
nis
So
bc
uta
ne
out
wwe
Fig.
35.Comparison of the angles
of insertion of IM
(90°), SubQ (45е), and
ID (15°) injections. A
SubQ may be given at
90° angle if a short
needle is used or if
the
patient
is
overweight.
MuKl
e
Giving an intradermal injection
Nursing Skill
Step 1. Assemble equipment and check physician's order. The right medication must be given to the right patient.
Step 2.Wash your hands. Wear gloves. Set up medication following safety
guidelines. This prevents contamination and decreases the possibility of
medication error. Gloves are worn because the patient's skin will be pierced.
Step 3.Explain to the patient what you are going to do and why. This
decreases the patient's anxiety and helps increase the patient's cooperation.
Step 4.Choose an injection site on the inner aspect of the forearm that is
not heavily pigmented or covered with hair and cleanse the site with an alcohol
pad in a circular motion and moving outward from the injection site. Allow skin
to dry. Upper chest or upper back beneath the scapulae also are sites for intradermal injections.
Step 5.Uncap the needle (usually 26- or 27-gauge needle) by pulling it
straight off and use your nondominant hand to spread skin taut over injection
site. Firmer skin makes it easier to access intradermal tissue but not
subcutaneous tissue).
Step 6.Place needle almost flat
against patient's skin, bevel up, at
a 10- to 15° angle and insert it
just until the bevel is no longer
visible (Fig.36).
Fig. 36. Giving an intradermal injection
Step 7.Slowly inject the
medication (solution quantity for injection is 0.2-0.3 ml or less). Watch for a
small blister or wheal to be appear. If none appears, withdraw needle slightly.
This indicates that the medication is correctly
placed. Intradermal sites can tolerate only small amounts of medication.
Step 8.Withdraw the needle quickly and at the same angle at which it was
inserted. This minimizes damage to the tissues. There must be no blood when
the needle is removed.
Step 9.Do not massage the site after removing needle. This could
displace the medication and give false readings to a test.)
Step 10.Discard the needle and syringe in the appropriate receptacle.
Lock the safety sheath in place. Do not recap the needle. (This decreases the
possibility of injury from a needle stick or infection.)
Step 11. Remove gloves, properly dispose of them and wash your hands.
Step12. Record the medication given, the site, and the patient's
response. Note when test results should be assessed in the chart.
Occasionally, the site is circled with pen. Test results can be false if not read at
the appropriate time. Marking the site can allow careful observation of the
correct area, especially if controls are used.
If the test is given to determine sensitivity, the injection site is checked at
48 and 72 h.The evaluation of the injection site is based on induration (a
hardness) and, to a lesser extent, on erythema (redness). Controls may be
given, along with the desired test material (such as tuberculin). This ensures
the person is producing antibodies.
Administering a subcutaneous injection
In subcutaneous injection ("SubQ"), a small amount of a drug is injected
into the subcutaneous tissue. This method is used to give drugs that are
soluble and nonirritating, such as insulin.
A subcutaneous injection is given in an area where bones and blood vessels
are not near the surface, commonly the upper
part of the arms and the thighs. For the occasional subcutaneous injection, the arm is
the most convenient site. If a patient is having
injections regularly, a different location is
chosen each time; for example, use the Fig.
37. Recommended sites for right arm, then
the left arm, then the right subcutaneous
injection
thigh, then the left thigh. The abdomen is also an area frequently used for
injections; the back may also be used (Fig. 37).
Recommendations as to angle of administration and length of needle
vary. The nurse must assess the patient's body mass and use judgment for
each patient. An undernourished or emaciated patient has less subcutaneous
tissue than a stouter person; a 1.1 cm needle is used. The solution is usually
injected at a 45°, but it may be necessary to increase this angle slightly. In a
very heavy person, a 90° is used because a short needle may not reach the
subcutaneous tissue. Using a needle that is too long can cause damage by
hitting a bone or a nerve; a 25- gauge needle is commonly used. Actions in
giving
a
subcutaneous
injection
are
given
bellow.
Giving a subcutaneous injection (Fig.38)
Nursing Skill
Stepl. Assemble equipment and check physician's order. Explain procedure to patient. Check any inconsistency with physician.
Step 2.Wash hands.
Step 3.Prepare medication. If necessary, withdraw from ampule or vial.
Step 4.Add air to syringe according to agency policy. For a heparin
injection, 0.1 mL of air is generally recommended to clear the medication from
the needle.
Step 6.Identify the patient before giving the medication. Medication may
be administered to the wrong patient if identity is not established.
Step 7.Put on gloves.
Step 8.Have patient assume a position appropriate for the most
commonly used sites. Select appropriate site using anatomic landmarks.
Locate site of choice (outer aspect of upper arm, abdomen, anterior aspect of
thigh, upper back, upper ventral or dorsogluteal area). Ensure that area is not
tender and is free of lumps or nodules. Correct identification of site decreases
the risk of injury.
Step 9.Clean area around injection site with an alcohol swab. Use a firm
circular motion while moving outward from the injection site. Allow area to
dry. Place alcohol swab on a clean, nearby surface. Cleansing injection site
with antiseptic prepares the site for the injection.
Step 10.Remove needle cap or retract sheath. Use nondominant hand to
grasp and bunch area surrounding injection site or spread skin at site. Size of
patient determines method of preparation of site. Skin that is spread taut
facilitates needle entry. Bunching the area, if patient has excess tissue, may be
necessary to ensure that needle is placed in subcutaneous tissue.
Step 11.Hold syringe in dominant hand between thumb and forefinger
(like a pencil or dart). This position prevents accidental loss of medication
while inserting needle.
Step 12.Insert needle quickly at correct angle, depending on amount and
turgor of tissue and length of needle. Quick entry of needle is less painful.
Correct angle delivers medication to subcutaneous tissue.
Stepl 3.After needle is in place, release tissue. If you have a large skin fold
pinched up, ensure that"the needle stays in place as the skin is released.
Immediately move your nondominant hand to steady the lower end of the
syringe. Slide your dominant hand to the tip of the barrel. This prevents
movement of the syringe, which can be painful for the patient.
Step 14.Aspirate, if recommended, by pulling back gently on syringe
plunger to determine whether needle is in the blood vessel. If blood appears,
the needle should be withdrawn, the medication syringe and needle discarded,
and a new syringe with medication prepared. Do not aspirate when giving
insulin or heparin.(Heparin is not aspirated because of its anticoagulant
activity.
Step 15.If no blood appears, inject the medication at a slow and steady
rate. Rapid injection may be painful for the patient.
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Step 16.Remove needle quickly at the same angle it was inserted. Slow
withdrawal of needle may be uncomfortable for the patient. * ч ^
Step 17.Massage area gently with alcohol swab unless contraindicated
for specific medication. Do not massage a subcutaneous heparin or insulin
injection site.
Step 18.Do not recap used needle. Place uncapped needle and syringe in
appropriate container. If using safety syringe, pull sheath over the needle, and
twist until it locks into place. Most accidental needle sticks occur while
recapping needle. Proper disposal prevents injury.
Step19. Assist patient to return to position of comfort. Remove gloves
and wash hands.
Step 20.Record medication administration on the appropriate form.
Indicate subcutaneous site that was used. Documentation provides
coordination of care. Rotation of sites prevents injury to subcutaneous tissue.
Step 21.Check on patient response to medication within appropriate
period of time. Drugs administered parenterally have a more rapid response.
Step 22.Remove gloves, properly dispose of them and wash your hands.
Fig. 38. Steps for giving a subcutaneous injection
Administering an intramuscular injection
In intramuscular (IM) injection, a drug is injected into the muscle beneath
the subcutaneous tissue. This method is used when giving irritating drugs or
large amounts of a drug because deep muscle tissue has fewer nerve fibers.
Also, larger doses can be given intramuscularly. Absorption of the drug is
faster because muscle tissue has a great number of blood vessels. The
injection is given in much the same way as a subcutaneous injection, except
that a longer needle is used and the drug is injected into muscles, instead of
into tissues directly beneath the skin. Most often a 1 1/2 to 2-inch, 20- to
22-gauge needle is used depending on the type of medication.
Step14.Aspirating for blood
Stepl 5.Injecting the medication
Intramuscular injections are more difficult and dangerous to give than
subcutaneous injections for several reasons. The needle must penetrate thick
muscles. If the drug is injected into subcutaneous tissues, it is not absorbed
quickly and may cause pain and serious irritation. The possibility of striking
bones, large nerves, and blood vessels is greater when a longer, larger needle
is used. Paralysis or nerve damage can result from injecting in
93
an incorrect site.
Injection sites
Intramuscular injections are usually given in the thick gluteal muscles of
the buttocks, although small injections may be given in the side of the thigh in
the vastus lateralis muscle (part of the quadriceps femoris) or in the outer part
of the upper arm in the deltoid muscle.
Any intramuscular injection must be given into healthy muscle tissue for
proper absorption to occur. If a patient requires intramuscular injections frequently, the sites should be rotated, and a notation of the site used each time
should be made on the patient's chart. The rotation of injection sites is
particularly important in the diabetic patient.
Giving an intramuscular injection (Fig.39)
Nursing Skill
Step 1.Perform hand hygiene.
Step 2.Assemble equipment and check physician's order. Check any inconsistency with physician.
Step 3.Prepare medication. If necessary, withdraw from ampule or vial.
Step 4.Explain procedure to patient.
Step 5.Identify the patient before giving the medication.There are three
ways to do this:
a) check the name on the patient's identification badge;
b) ask the patient his or her name;
c) verify the patient's identification with a staff member who knows the
patient.
Step 6.Have patient assume a position for the site selected. Locate site of
choice and ensure that the area is not tender and is free of lumps or nodules.
-Ventrogluteal (side hip) - patient may lie on back or side with hip and
knee flexed.
-Vastus lateralis (side thigh) - patient may lie on the back or may assume
a sitting position.
-Deltoid (upper arm) - patient may sit or lie with arm relaxed.
-Dorsogluteal (back of hip) - patient may lie prone with toes pointing
inward or on side with upper leg flexed and placed in front of lower leg.
PEDIATRIC ALERT. For infants and children, the vastus lateralis muscle of
the thigh is used most often because it's usually the best developed and
contains no large nerves or blood vessels, minimizing the risk of serious
injury. The dorsogluteal site should not be use in infant under 3 years because
the gluteal muscles are not well developed yet.
Step 7.Put on gloves.
Step 8.Select appropriate site using anatomic landmarks.
Step 9.Cleanse area thoroughly with an alcohol swab, using friction. Start
at site and move outward with a circular motion. Allow area to dry. Place
alcohol swab on a clean, nearby surface or hold between fingers of
nondominant hand. Cleansing injection site with antiseptic prepares the site
for the injection.
Step 10.Remove needle cap by pulling it straight off. Use nondominant
hand to spread tissue at injection site. Skin that is spread taut facilitates needle
entry.
Step 11. Hold syringe in your dominant hand between thumb and forefinger (like a pencil or dart). This position keeps finger off plunger, preventing
accidental loss of medication while inserting needle. As soon as needle is in
place, release skin and move your nondominant hand to hold lower end of
syringe. Slide your dominant hand to tip of barrel. This prevents movement of
the syringe, which can be painful for the patient.
Step 12.Quickly insert needle into the tissue at 90° angel. Insertion is less
painful and enters muscle tissue.
Step 13.Aspirate slowly (for at least 5 seconds), pulling back on plunger
with dominant hand to determine whether the needle is in a blood vessel. If
blood is aspirated, discard needle, syringe and inject in another site. A blood
return indicates intravenous placement of needle. Medication becomes contaminated by blood and must be redrawn.
Step 14.If no blood is aspirated, inject solution slowly (10 seconds per ml
of medication). Rapid injection may be
painful for the patient.
Step 12. Inserting the needle
Step 8. Selecting the
appropriate site using
anatomic landmark
Stepl 4. Intramuscular injection of
solution
Step 13. Aspirating for blood Fig.39. Steps for giving intramuscular injections
Step 15.Use nondominant hand to spread skin around needle entry site.
Remove the needle quickly at the same angle it was inserted. Slow withdrawal
of needle may be uncomfortable for the patient. Taut skin provides for easier
removal of needle. Apply gentle pressure at site with small sponge. Massaging
the site promotes absorption of the medication and increases patient comfort.
Step 16.Do not recap used needle. Place uncapped needle and syringe in
appropriate container. Most accidental needle sticks occur while recapping
needle. Proper disposal prevents injury.)
Step 17.Assist patient to return to a position of comfort.
Step 18.Remove gloves and wash hands.
Step 19.Record medication administration on the appropriate form.
Indicate intramuscular site that was used.
Step 20.Check on patient response to medication within appropriate
period of time.
Intravenous Injection
A drug may be injected intravenously (IV), directly into a vein (given
intravenously, to obtain the needed effect quickly or when it is impossible to
inject the drug into other tissues. A large quantity of solution is given by
infusion, that is, the solution flows into the patient's vein with the aid of gravity
or an infusion pump. The starting of an intravenous injection (venipuncture)
requires technical skill and usually must be done by a physician or registered
nurse. Intravenous infusion is commonly given for dehydration and excessive
loss of blood, to dilute poisons in the blood and other body fluids, or to
provide electrolytes, drugs, and nutrients. If blood is given, this method is
called a transfusion. Drugs are not added to a blood transfusion.
Intravenous infusion is widely used. You will not be responsible for
starting an infusion, but you should know how to care for a patient who is
having this treatment. Usually, a plastic catheter is inserted into a vein.
Attached to it is a length of tubing connected to a plastic bag containing the
prescribed solution. A clamp on the tubing regulates the flow of fluid. In many
hospitals, an electronic infusion pump is used to regulate the drip rate of the
intravenous infusion. In some situations when the fluid is being infused into an
arm vein, the arm may be immobilized. This is less common with a catheter
than with a needle in the vein.
Many drugs, including antibiotics, electrolytes, and vitamins, are
commonly added to an intravenous infusion. Most hospital pharmacies add
the drugs ordered by the physician to the intravenous solution. Medications
may be added to intravenous solutions in a laminar flow hood, which reduces
the risk of contamination. Because of the growing number of drugs
administered intravenously and the dangers of drug incompatibilities, having
the pharmacy personnel prepare the solutions reduces the chances of
dangerous drug or electrolyte combinations and of errors in mixing
medications
Giving intravenous injection
Nursing skill
Step 1.Perform hand hygiene.
Step 2.Assemble equipment and check physician's order. Check any
inconsistency with physician.
Step 3.Prepare medication. If necessary, withdraw from ampule or vial.
97
Step 4.Explain procedure to patient.
Step 5.Select the largest vein suitable for an injection. The larger the vein,
the more diluted the drug will become, minimizing vascular irritation.
Step 5.Apply a tourniquet above the injection site to distend the vein.
Step 6.Clean the injection site with an alcohol pad, working outward from
the puncture site in a circular motion to prevent recontamination with skin
bacteria.
Step 7.If you're using the drug syringe's
needle, insert it into the vein at a
30-degree angle with the bevel up. The
bevel should reach 0.6 cm into the vein
(Fig.40). If you're using a winged-tip
needle, insert the needle (bevel up),
tape the butterfly wings in place when
you see blood return in the tubing, and
attach the syringe containing the
medication.
Fig. 40. Inserting a needle
Step 8.Pull back on the syringe
plunger, and check for blood backflow, which indicates that the needle is in
the vein.
Step 9.Remove the tourniquet and inject the medication at the
appropriate rate.
Step 10.Pull back slightly on the syringe plunger and check for blood
back- flow again. If blood appears, this indicates that the needle remained in
place and all the injected medication entered the vein.
Step 11.Flush the line with the normal saline solution from the second
syringe to ensure delivery of all the medication.
Step 12.Withdraw the needle and apply pressure to the injection site with
a sterile gauze pad for at least 3 min to prevent hematoma formation.
Step 13.Apply the adhesive bandage to the site after bleeding has
stopped.
4.3. Drug dosage calculation and administration
Accurate calculating of drugs is vital in Nursing. Nurses must know how
to calculate required dosages accurately and efficiently. This requires some
basic mathematics: addition, subtraction, multiplication and division. The
difficulty of the calculation is what to do and when to do it.
Methods of Calculation
Nonparenteral Medications
Any of the following methods can be used to perform drug calculations.
Remember: Before doing the calculation, convert units of measurement
to one system.
I. Basic Formula: Frequently used to calculate drug dosages.
D
(Desired
dose)
98
H (Dose on hand)
V (Vehicle-tablet or liquid)
jjj x V = Amount to Give
hand
D = dose ordered or desired dose = dose on container label or dose on
V = form and amount in which drug comes (tablet, capsule, liquid)
II. Ratio &Proportion: Oldest method used in calculating dosage.
Known
Desired
H: V ::D : X Means
Extremes
-Left side are known quantities.
-Right side is desired dose and amount to give.
-Multiply the means and the extremes.
HX = DV
X=
Points to remember:
1.
The maximum number of tablets and capsules administered to
achieve a desired dose is usually 3.
2.No more than 10% variation should exist between the dose ordered and
the dose administered.
3. Make sure your answer seems reasonable. Think about whether the
dose should be larger or smaller than what is available.
Parenteral Medications
The same methods, ratio-proportion or formula, are used to determine
the amount to be given.
Injectable medication guidelines:
1. Intradermal - the volume to be administered is 0.1 ml or less.
2. Subcutaneous - the volume to be administer is 1.0 ml or less.
3. Intramuscular-depends upon the size of the person:
- a healthy well developed person can tolerate 3.0 ml in large muscles this does not include the deltoid;
- for elderly, thin clients or children the total amount should not exceed
2.0 ml;
- no more than 1.0 ml should be given to young children and older
infants.
Pediatric calculations
Accurate doses are especially important in giving medications to infants
**
and children because even small errors can be dangerous due to their small
body size.
Two methods are used to calculate pediatric dosages:
I.
According to the weight in kilograms (kg).
99
II.
According to the child's body surface area (BSA).
I. Calculations based on body weight
The first step is to measure the child's body weight in kg.
The second step is to calculate the medication dose:
a.
calculate the daily dose;
b.
divide the daily dose by the number of doses to be administered;
c.
use either the ratio-proportion or formula method to calculate
the number of tablets/ capsules or volume to be administered with each dose.
Example: A child weighing 34.5 kg is ordered to receive 150 mg of Clindamycin q6h. The pediatric drug handbook states the recommended dose is
8-20 mg/kg/day in four divided doses. The Clindamycin is supplied in 100 mg
scored tablets.
Step 1. What is the safe total daily dose?
Minimum: 8 mg/kg/day X 34.5 kg = 276
mg/day Maximum: 20 mg/kg/day X 34.5 kg =
690 mg/day Step 2. Is this a safe dose? 150
mg/dose X 4 doses/day = 600 mg/day Yes,
this is within the recommended safe range.
Step 3. Calculate the number of tablets to give.
100 mg:1 tablet =150 mg:x 100x = 150 x=1.5
tablets
II. Calculations based on body surface area (BSA)
BSA is determined from a nomogram using the child's height and weight.
When you know the child's BSA the dosage is determined by multiplying
the BSA by the recommended dose.
To determine whether the dose is safe, compare the ordered dose and the
calculation based upon the BSA.
The formula for calculating child's dosage is
Child's BSAv л , |+гл 1 7m2
------- X Adult Dosage
4.4. The technique of performing intravenous infusions
Intravenous infusions (an intravenous drip) is the continuous infusion of
fluids, with or without medications, through an IV access device. This may be
to correct dehydration or an electrolyte imbalance, to deliver medications, or
for blood transfusion.
There are two types of fluids that are used for intravenous drips;
crystalloids and colloids. Crystalloids are aqueous solutions of mineral salts or
other water- soluble molecules. Colloids contain larger insoluble molecules,
such as gelatin;
blood itself is a colloid.
Colloids preserve a high colloids osmotic pressure in the blood, while, on
the other hand, this parameter is decreased by crystalloids due to
hemodilution. However, there is still controversy to the actual difference in
efficacy by this difference.
The most commonly used crystalloid fluid is normal saline, a solution of
sodium chloride at 0.9% concentration, which is close to the concentration in
100
the blood. Ringer's lactate or Ringer's acetate is another isotonic solution often
used for large-volume fluid replacement. A solution of 5% dextrose in water,
sometimes called D5W, is often used instead if the patient is at risk for having
low blood sugar or high sodium. The choice of fluids may also depend on the
chemical properties of the medications being given.
Intravenous fluids must always be sterile.
Giving intravenous infusion
Nursing Skill
Step 1. Gather equipment and bring to patient's bedside. Check
medication order against physician's order. Check a drug resource to clarify if
medication needs to be diluted before administration.
Step 2.Explain procedure to patient.
Step 3.Perform hand hygiene. Put on gloves.
Step 4.Prepare IV solution and tubing:
a. maintain aseptic technique when opening sterile packages and IV
solution;
b. clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs;
c. squeeze drip chamber and allow it to fill at least halfway;
d. remove cap at end of tubing , release clamp, and allow fluid to move
through tubing. Allow fluid to flow until all air bubbles have disappeared.
Closed clamp and recap end of tubing, maintaining sterility of setup;
e. apply label if medication was added to container. (Pharmacy may have
added medication and applied label.)
Step 5.Assist patient to a comfortable position. Place protective towel or
pad under patient's arm.
Step 6.Select appropriate site and palpate accessible veins.
Step 7.Apply tourniquet to obstruct venous blood flow and distend vein.
Direct tourniquet ends away from entry site. Check to be sure radial pulse is
still present.
Step 8.Ask patient to open and close his or her fist. Observe and palpate
for a suitable vein. Try the following techniques if vein cannot be felt:
a) release tourniquet and have patient lower his or her arm below the
level of the heart to fill the veins.
b) reapply tourniquet and gently tap over the intended vein to help distend it;
Step 9.Don clean gloves.
*<
Step 10.Cleanse the entry site with an antiseptic solution (alcohol swaty
followed by antimicrobial solution (povidone iodine) according to agency
policy. Use a circular motion to move from the center outward for several
inches.
Step 11.Use the nondominant hand, placed below entry site, to hole skin
taut against vein. Avoid touching prepared site.
Step 12. Enter skin gently with catheter held by the hub in the dominanl
hand, bevel side up, at a 10- to 30° angle. Catheter may be inserted from eithei
directly over vein or from side of vein. While following the course of the vein,
101
advance needle or catheter into vein. A sensation of "give" can be felt when
needle enters vein.
Step 13.When blood returns through lumen of needle or flashback
chamber of catheter, advance either device Vi to inch farther into vein. A
catheter needs to be advanced until the hub is at the venipuncture site, but the
exact technique depends on the type of device used.
Step 14.Release tourniquet. Quickly remove protective cap from IV tubing
and attach tubing to catheter or needle. Stabilize catheter or needle with
nondominant hand.
Step 15.Start solution flow promptly by releasing the clamp on the tubing. Examine the tissue around entry site for signs of infiltration.
Step 16.Secure the catheter with narrow nonallergenic tape placed sticky
side up under hub and crossed over the top of the hub.
Step 17.Place sterile dressing over venipuncture site. Agency policy may
direct nurse to use gauze dressing or transparent dressing. Apply tape to
dressing if necessary. Loop tubing near site and anchor to dressing.
Step 18.Mark date, time, site, and size of catheter used for infusion on
the tape. Anchor tubing.
Step 19.Anchor arm to an armboard for support, if necessary, or apply
site protector or tube-shaped mesh netting over insertion site.
Step 20.Adjust rate of solution flow according to amount prescribed or
follow manufacturer's directions for adjusting the flow rate infusion pump.
Step 21.Remove all equipment and dispose of in proper manner. Remove
gloves and perform hand hygiene.
Step 22.Chart administration of medication.
Step 23.Return to check flow rate and observe for infiltration 30 minutes
after starting infusion.
Step 24.Evaluate patient's response to medication within appropriate
timeframe.
Possible Complications of intravenous therapy
Adverse reactions in intravenous therapy:
- Infiltration
- Area feels cold and hard to the touch
- Pain and burning sensation at the site
- Blood does not return in the tubing when the bag is lowered below the
level of the patient
- Edema
- White, raised area on the arm
- Flow rate may or may not be slow
Fluid overload
- Increased pulse rate
- Dyspnea
- Increased blood pressure
- Engorged neck veins
Inflammation or phlebitis
- Redness and warmth along the vein
- Pain or burning sensation at the site
102
- Slow flow rate
- Tenderness
- Edema of the vein above the insertion site
- Hardened feel to the vein
Infection
- Fever
- Chills
- Redness, swelling, or discharge at the insertion site
- Malaise
If you see any of these signs, discontinue the intravenous infusion as
soon as possible and notify the physician.
4.5. Medical instrument disinfection and sterilization
In a hospital or clinic it is necessary that all equipment and materials used
for treating patients are absolutely safe for use: the chance for spreading of
diseases should be kept as small as possible. Cleaning, decontamination and
sterilization are important methods in the battle against this ever present
threat. Especially since the fatal disease AIDS became so powerful and spread
world wide, the demand for proper procedures for infection control gained
momentum enormously. Diseases such as Hepatitis B, known to be transmitted
through contaminated surgical instruments, stimulated the need for stricter
guidelines for disinfection and sterilization. All sterilization, disinfection and
cleaning needs including training staff and monitoring results.
General principles of disinfection and sterilization
1. In general, reusable medical devices or patient-care equipment that
enters normally sterile tissue or the vascular system or through which blood
flows should be sterilized before each use.Sterilization is a process intended to
kill all microorganisms and is the highest level of microbial kill that is possible.
Sterilizers may be heat only, steam, or liquid chemical. Effectiveness of the
sterilizer (often called "an autoclave") is determined in three ways. First - by the
mechanical indicators and gauges on the machine itself, second - the heat
sensitive indicators or tape on the sterilizing bag turn color, and thirdly - and
most importantly is the biological test. With the biological test, a highly heat
and chemical resistant microorganism (often the bacterial endospore) is selected as the standard challenge. If the process kills this microorganism, the
sterilizer is considered to be effective. It should be noted that in order to be
effective, instruments must be cleaned, otherwise the debris may form a protective barrier, shielding the microbes from the lethal process. Similarly care
must be taken after sterilization to ensure sterile instruments do not become
contaminated prior to use.
2. Disinfection refers to the use of liquid chemicals on surfaces and at
room temperature to kill disease causing microorganisms There are three
levels of disinfection: high, intermediate, and low. High-level disinfectants
destroy all microorganisms, with the exception of high numbers of bacterial
spores. Intermediate-level disinfectants inactivate even resistant organisms
such as Mycobacterium tuberculosis, as well as vegetative bacteria, most
103
viruses, and most fungi, but do not necessarily kill bacterial spores. Low-level
disinfectants kill most bacteria, some viruses, and some fungi, but cannot be
relied on to kill resistant microorganisms such as tubercle bacilli or bacterial
spores.
3. Heat stable reusable medical devices that enter the blood stream or
enter normally sterile tissue should always be reprocessed using heat-based
methods of sterilization (e.g., steam autoclave or dry heat oven).
1. Laparoscopic or arthroscopic telescopes (optic portions of the endoscopic set) should be subjected to a sterilization procedure before each use; if
this is not feasible, they should receive high-level disinfection. Heat stable
accessories to the endoscopic set should be sterilized by heat-based methods.
2. Reusable devices or items that touch mucous membranes should, at a
minimum, receive high-level disinfection between patients. These devices include reusable flexible endoscopes, endotracheal tubes, anesthesia breathing
circuits, and respiratory therapy equipment.
3. Medical devices that require sterilization or disinfection must be
thoroughly cleaned to reduce organic material or disburden before being
exposed to the germicide.
4. Except on rare and special instances, items that do not ordinarily touch
the patient or touch only intact skin are not involved in disease transmission,
and generally do not necessitate disinfection between uses on different patients. These items include crutches, bed boards, blood pressure cuffs, and a
variety of other medical accessories. Consequently, depending on the
particular piece of equipment or item, washing with a detergent or using a
low-level disinfectant may be sufficient when decontamination is needed.
Sterilization of equipment
Many steps are required to ensure that instruments are appropriately
sterilized. These include pre-cleaning, cleaning, milking, inspection, packaging, wrapping, autoclaving and maintaining the autoclave.
Pre-cleaning needs to be done at the point of use to prevent the drying of
organic material. This can be accomplished by either wiping the instrument
with a wet cloth or placing the instrument in an enzymatic cleaner.
Cleaning includes many steps. Staff should wear appropriate personal
protection equipment and follow approved procedures to prevent BBP (blood
borne pathogen) exposure.
Milking. After cleaning, instruments with moveable parts need to be immersed in a milk solution and removed without rinsing. All instruments should
be inspected before wrapping. It is important to ensure that hinged
instruments open easily and that the jaws are properly aligned. Sharp
instruments should be inspected for sharpness. All instruments should be
inspected for cracks, chips or worn spots, with any instruments found with
defects removed from service and sent for repair.
After inspection, wrap instruments in a single pouch of an appropriate
size. Store all instruments in the open position with any curved tips pointed in
the same direction. A steam indicator should be placed in the center of the
pack with one end visible when the pack is opened. Secure the packet with
104
steam indicator tape and labeled with the date of sterilization, the load number
and the initials of the person preparing the package.
Autoclaving or other sterilization methods should be done following
manufacturer's directions. Keep a log that details each time the equipment is
run, every time a biological indicator is sent and every time maintenance is
performed. Staff should be able to verbalize the recall/resterilization
procedure in case of failure of the biological indicator, visible condensation
seen in a package, indicators that do not appropriately change color, and
package integrity concerns or compromised storage and handling conditions.
Nurses maintain the immediate health care environment. Because they
provide care for a variety of patients, the risk of contamination from
pathogenic microorganisms is increased. The practice of medical asepsis and
standard precautions provides the nurse with techniques for destroying or
containing pathogens and for preventing contamination to other people or to
bedside materials and equipment.
Universal precautions dictate that needles not be recapped after use. This
helps to prevent a needle stick to the nurse. Diseases such as acquired
immunodeficiency syndrome and hepatitis В are spread by contaminated body
fluids, such as blood.
Be careful when placing needles in the «sharps» container and when
carrying a used syringe/needle.
Dispose of used syringe/needles immediately. Most hospitals have a
sharps disposal container in each room. Otherwise, there are containers on the
medication and treatment carts.
Any finger stick is potentially dangerous to the nurse and must be
reported immediately.
If a needle must be recapped, place the cap on a level surface and "scoop"
it up with the needle. Do not touch the cap while this is being done.
- Small styrofoam-filled boxes are also available. Stick the needle into the
styrofoam to prevent accidental finger sticks while transporting the equipment
back to a sharps disposal container.
There are new devices available for recapping needles that will prevent
needle sticks, such Gard Recapper. These devices allow the nurse to uncap and
recap the needle without danger. After the Recapper removes the needle, the
syringe is placed in the attached reusable container, which is lined with a
disposable plastic bag. A standard sharps container can hold500needles. This
reduces the volume of sharps waste and reduces a typical physician's
needle/syringe disposal cost by an average of40%,depending on the volume.
Tests for self-training
Ql.The physician orders you to give an IM medication to a 2-year- old
child. What site will you use?
A. The vastus lateralis.
B. The ventrogluteal.
C. Deltoid.
D. Dorsogluteal.
Q2.The main complication after an intramuscular injection is:
A. Abscess.
B. Tissues necrosis.
105
C. Hemorrhage. D. Phlebitis.
E. Air embolism.
Q3.The most appropriate site for hypodermic injections is:
A. The high external quadrant of buttocks muscles.
B. The front external region of a shoulder or a hip.
C. The cubital region.
D. The knee region.
E. The front of forearm region.
Q4. All the means given below are used for prophylactic disinfection
except:
A. Quartz lamps in wards.
B. Wards airing.
C. Disinfection of furniture and toys with 1 % chloride of lime solution.
D. Thermometer disinfection with 3% hydrogen peroxide solution.
E. Floor sweeping.
Q5. Skin test for antibiotic in patient with pneumonia is positive. Your
actions:
A. Do not inject this antibiotic
B. Continue injection under the care of a physician.
C. Continue injection after introduction of antihistamine.
D. Giving antibiotic intravenously.
E. inject 1/гdose intramuscularly and У2 - intravenously.
Q6. Which vein is used for infant for giving an intravenous infusion:
A. Superficial popliteal vein.
B. Superficial cubital vein.
C. Carpal vein.
D. Femoral vein.
E. Temporal vein.
Q7. Which method of introduction of medicine in a five-year-old child
with vomiting and diarrhea is more reasonable:
A. intravenous.
B. peroral.
C. rectal.
D. inhalation.
E. subcutaneous.
Q8. What is incorrect during setting medications into a syringe
A. Opening of metallic lid of small bottle is executed.
B. It is necessary to read the name of a medication.
C. It is necessary to conduct treatment of rubber cork by ethyl alcohol.
D. It is necessary to put on rubber gloves.
E. It is not obligatory to deflate air from the syringe.
Q9. During intramuscular injection all listed bellow is correct, except:
A. Cleanse area thoroughly with an alcohol swab.
B. A needle is inserted into the tissue at 45-degree angel.
C. An injection can be conducted in the external overhead quadrant of
area of buttock.
D. After njection the tissue should be cleaned once more with an alcohol
swab.
E. Spread skin around needle entry site.
Q10. Subcutaneous injection is not given into:
Upper part of shoulder.
106
Upper part of thigh.
Abdomen.
Cubital fossa.
Key answers: Q1- D; Q2- A; Q3 -B; Q4- E; Q5- A; Q6 -E; Q7- A;
Q8 -E; Q9 -B; Q10- D.
CHAPTER 5.
DUTIES OF THE NURSE ON PROVIDING THE PERSONAL HYGIENE FOR
CHILDREN OF DIFFERENT AGE
5.1. Special rules of hygiene of children of the first year of life.
Intimate washing of girls. Types of baths
The infant is usually given a tub bath in a small bedside tub. Be sure to
bring all the equipment needed when the bathing is started, because the child
cannot be left alone after the bathing has begun. For bathing a child it is
necessary to have a baby's bath, child's soap, a soft sponge, an aquatic
thermometer, and a jug with warm water for rinsing the child, as well as a
diaper and a sheet. Before every bathing, the baby's bath is washed with a
brush and soap, and rinsed out with cold water, and then scald boiling water. If
the bathing is conducted at a children's establishment, the baby's bath is
treated with some disinfectant solution and scald boiling water. It is better to
keep the baby's bath in the vertical position and use only for child's bathing.
A sponge bath is the best way to clean baby until the umbilical cord falls
off. To give a sponge bath, dip a soft cloth in the warm water and wring out the
excess. If needed, a mild soap can be used in the water. Wipe the baby's skin
gently starting from the area of the baby's head and work your way down to the
rest of the body. It is, however, important to wash infant's skin folds, such as
the neck, armpits, buttock and genital areas daily with warm water and a mild
infant soap. Washing these areas prevents the accumulation of milk, urine and
stool in folded areas, which could cause skin irritation. Be sure to dry these
areas thoroughly. Rinse baby with clean warm water and dry him or her completely.
During the first 6 months it is desirable to bathe a child every day, from 6
to 12 months - every other day, and then - twice a week, but, when it is possible, even more frequently. The diapers and sheets are prepared beforehand
in order to wrap the baby right away after the bathing and not to give it time to
get cold. If the temperature at the room is below 22°C, the baby's diapers are
preliminarily warmed up.
Guidelines for Bath
- Decide where you want to bathe baby.
- Gather any supplies so they are handy and easily accessible.
- Have a dry towel ready to wrap baby up.
- Check the water temperature since baby's skin is very sensitive.
- If baby has cradle cap, you might want to use a mild baby shampoo and
a scrub brush (but usually this clears up with time rather than scrubbing).
- Wash, rinse, dry and moisturize.
Note: Wait to fully immerse a baby until after the umbilical stump has
fallen off. And, never leave her unattended in any amount of water.
107
Proper infant bathing techniques
The water temperature is very important - it should be around 37°C-37
.5°C. If you are filling the bath from a tap always run the cold water first, and
then add the hot water until the temperature feels just right. You could also
half-fill some buckets with water and carry them to the baby bath. Never try to
carry a full bath of water around. Throughout the bath, talk to baby and smile
at him to help make it an enjoyable experience for you both.
If the umbilical wound has not healed or there are some skin changes, add
a few drops of a preliminary prepared strong solution of potassium permanganate to the water for bathing, but not crystals of manganese, because
they can burn the delicate child's skin.The water must be pinky. In addition, the
child bathing can be conducted in decoctions of herbs (celandine, tickseed,
chamomile, etc.). It is desirable to take the boiled water for bathing during the
first month of child's life. Children are bathed in the evening before feeding,
but it is possible to do this in another time.
The water temperature should be about 36.5-37°C for 2-6 month-old
babies, and 36-36.5°C - after 6 months.
Newborn infants do not require daily baths, as most adults do. In fact, it is
better to bathe infant no more than every 3 or 4 days. The head should be
washed with baby shampoos, which are formulated specially for treating cradle
cap, especially if the baby has a scaly, greasy scalp. If necessary, you can rub in
a little olive oil to soften the scales and speed up the process. (Avoid using
almond oil or other nut oils because of the risk of allergy). They do dissolve
some of the dead skin, but they do not work any better than olive oil.
When setting up for the bath you'll need to make sure that you have everything you might need right in front of you so that you won't have to turn
away from the baby even for an instant. Line up the soap, towel, lotion,
washcloth, and small cup next to the sink or baby basin. Then, fill it up with
just a very shallow amount of water, not even half an inch, and make sure that
the water is lukewarm as an infant's skin is very sensitive. Place the baby gently
into the water, elevating their heads so that no water gets into their ears.Then,
wash them all over with the washcloth and the soap. Rinse them off with water
from the cup, or you can get some water in the palm of your hand and push it
over the baby's skin until the soapy residue is gone.
Remember, never leave baby alone or set them down in the water for any
reason as they might roll over and breathe in the water accidentally. This can
occur even in a brief moment, so that's why it's important to not leave them
unattended even for a split second.
The duration of bathing for children of first six months is 3-5 min, from 6
to 12 months - 6-8 min, and after 1 year - 8-12 min. Older children are
hygieni- cally bathed once a week. On that day, bed linen and cloth are to be
changed. If necessary, the bed linen and cloth are changed more frequently.
Perineal and genital care. After every defecation and urination, in order to
prevent any intertrigo, it is recommended to wash the child with warm running
water; particularly the girls must be held with their face up and washed from
the front to the back to avoid faeces falling into the vagina and their urination
tract infecting. If the girls have some secretion from the vagina it is necessary
to carry out the toilet of their genitals with cotton wool moistened in the
108
solution of furacillin (1:5000) or manganese potassium. After washing, the skin
should be rather carefully dried with a soft diaper; if any problems appeared
during the skin care, all the folds are dubbed with sterilized oil or baby oil;
baby creams can be used too.
If the child is on the absolute bed rest, a bedpan (enameled or rubber) is
put under or a urinal (enamel or glass) is given. A patient allowed to get up is to
use a pot placed under the bed. A bedpan, urinal or pot should be washed with
warm water together with some cleansing agent and then be specially
disinfected every day. For suppression of the urine odour, the above vessels
should be treated with a dilute potassium permanganate solution.
Hygienic and medicated baths are divided into general and local. Depending on the water temperature, the baths are classified as:
- hot (40°C, but no more than 41 °C),
- warm (38°C),
- indifferent (37°C),
- cool (30-33°C),
- cold (below 28°C).
Medicinal baths can be supplemented with pharmaceutical substances
and herbs.
Fresh warm baths. Indications: rickets, allergic dermatitis, skin diseases,
kidney diseases, pneumonia, poliomyelitis, neuroses, disturbances of the
locomotor apparatus. The water temperature should be 38°C. The bath
duration: 5-15 min; each course includes 8-15 procedures.
General hot baths. Indications: pneumonia, bronchitis, nephritis, etc.
Contraindications: cardiac insufficiency.Technique: a child is put into the bath
with the water temperature of 36-37°C, and then some hot water is gradually
added to the foot end of the bath by a thin jet with continuous mixing. The
temperature is raised up to 40°C. The bath duration:8-10 min. A cold compress is usually put on the child's head. As a result, the baby's skin becomes
pinky. The child should be rinsed with pure warm water, made dry and carried
to a preliminary warmed-up bed.
Mustard baths. Indications: pneumonia, bronchitis and other respiratory
diseases. 40-50 g of dry mustard are dissolved in 101 of water. Contraindication: respiratory allergosis, skin diseases. Duration:5-6 min. The water
temperature should be 37-37.5°C. A cold compress should be putted on the
child's head. The footbath is made in the same way, but the water temperature
in this case should be higher by 2-3°C and the duration of the bath may be
longer.
Starch baths. Indications: eczema and other skin disorders for the elimination of itch and irritation. 100 g of starch are dissolved in 10 I of water. The
water temperature is 37°C. Course- 5-6 procedures.
Baths with the potassium permanganate. Indications: pyodermatitis and
other skin disorders. This bath has disinfecting effect. The water temperature
should be 36-37°C, the duration- 9-10 min, course- 8-10 baths. Potassium
permanganate solution (5%) is added at a rate of 5 ml of the solution per 10
litres of water (until the water becomes pinky).
109
Note! It is prohibited to dissolve crystals of potassium permanganate
directly in the bath! The crystals may cause skin necrosis!
Salt bath. Indications: rickets in the recovery period, hypotrophy. 50-100
g of salt (better sea salt) is dissolved in 10 I of water. The water temperature for
children from 6 months to 1 year should be 35-36°C, then it makes up to 32 °C.
Duration- 3-10 min. After every 3-4 baths, the duration of the procedure
increases by 1 min. After the salty bath the child should be rinsed with the
water by 10°C colder than in the very beginning. Contraindications: exhausted
children, children with skin disorders (weeping eczema, allergic rash, etc.),
children with an imbalanced nervous system.
Coniferous baths. Indications: rickets, insomnia, neurosis, rheumatism,
hypotrophy, respiratory system disorders in the recovery period. 1 tablespoon
of the coniferous extract is dissolved in 201 of water. The water temperature
should be - 36-37°C. Duration- 7-10 min, course -15-20 baths every other
day. After the bath, the child should be rinsed with the water by 10°C colder
than in the bath.
Salty-coniferous baths. Indications: paratrophy, rickets in the recovery
period. The water temperature should be 35-36°C, duration- 5-10 min.
Course -15-20 baths every day.
Hand bath is applied in respiratory disease. The water temperature should
be 37-40°C, the duration-10-15 min. One or both hands of the child should be
submerged in water up to the elbow. In order to increase the irritable action, it
110
is possible to add a bit of dry mustard to the water.
Foot-bath. Water with the temperature above 36-37°C is to be poured
into an enameled bucket or tank. Drop the child's feet in and gradually tap up
hot water in order to achieve 40°C. Duration- 10-15 min, after that the feet
should be wiped dry, then cotton socks, followed by woolen ones, are put on
the child. The child is to be lifted in a semi-sitting position and tightly covered.
Note! If in the process of bathing a child gets pale, complains of
dizziness, it is necessary to pull him out of the bath immediately, put on a
couch with a raised lower end, bring ammonia spirit to the child's nose and rub
his temples.
5.2. The technique of oral hygiene, eye, ear and nose care
Oral Hygiene. It is not necessary to clean the mouth of a healthy infant,
because, when sponging down, it is possible to easily injure the mucosa and
cause an inflammatory process in it, but the toilet of the oral cavity is required
in oral moniliasis (candidiasis). Technique: by a separate bolster, moistened in
2% baking soda solution, oral mucosa is treated in the following order: mucous
membranes of the tongue, hard palate, cheeks, and vestibule.
By the age of 3 years, the child should be able to brush his teeth under an
adult's supervision after a meal and before sleep, to brush the teeth in the
morning and in the evening. Paediatric dentists now encourage this type of
oral hygiene for all infants. Children's toothpaste is used by putting it on a
child's toothbrush of an adequate size. The teeth are brushed from their external and internal sides by moving the toothbrush from up to down and from
down to up. It is desirable that children rinse a mouth after every meal with
warm water, better with an addition of some salt (a quarter of tea-spoonful of
table salt per glass of water) or soda water (3-5 g of sodium bicarbonate per 1
cup of water). By the age of 8 years, the child should be independent in brushing or flossing, with an occasional checking by a nurse. You may need to teach
these procedures to the child.
The nurse must assist with brushing the teeth. All children should be
encouraged to often rinse their mouth with water. If the child is mature enough
to rinse the mouth and spit the
solution
out,
a
well-diluted
mouthwash can be used.
The care of the eyes is conducted 2 times a day (in the morning
and in the evening before bathing),
and also whenever necessary. Healthy
eyes are cleaned with a cotton ball,
soaked in some boiled water. Clean
the eye corners, by wiping gently from
the outside corner to the inside corner
Fig. 41. The care of the eyes
and using a different piece of cotton
for
each
eye
(Fig.
41).
111
Some paediatricians advice to clean first with pure water from the inner
corner to the outer one. In case of risk of the appearance of conjunctivitis or in
seriously ill children, the eyes may be washed with furacilin solution (1:8000)
or any other mild disinfectant. Older children usually make the toilet of their
eyes when washing.
The nose is cleaned in the morning and daily, and ^' ■■■'*:-,•
..............................................
especially when a baby often belches or
Щ
has catarrhal secretions from his nose.
For the cleaning nasal cavity, a thin
flagel- lum of cotton wool is used (Fig.
42). Before cleaning, the cotton
flagellum is moistened with seed-oil and
put
into the nasal cavity at a depth of 1 -1.5
cm
with circular movements. The nasal
cavity is cleaned with different flagellum
in
turn. It is not allowed to use matches, sticks
Fig. 42. The care of the nose
and other hard
objects. If a baby has a lot of mucus due to a cold nose, it should be removed
with an infant nasal aspirator.
The ear care is carried out with cotton wool, moistened with boiled water
(Fig.43). There is no way for using
hard things (sticks, matches) that can
damage the skin of the external
acoustic meatus and eardrum. The
manipulations require much attention
and great care. Drawing off an auricle
backwards and upwards with his/her
left hand, a nurse places a bundle into
the acoustic meatus, making a
number of spinning movements, and
then extracts the bundle. When it is
Fig. 43. The ear care
necessary, the bundle is changed and
the manipulation is repeated.
The care of the nails. Fingernails and toenails are to be cleaned. Many
hospitals do not allow nails to be trimmed without a special physician's order.
Oil or lotion may be applied to irritated areas. Nails are trimmed timely, unless
once a week, so that the length of their free edge does not exceed 1.0-1.5
mm. Nails are trimmed carefully, only with scissors having blunt ends; on the
fingers circularly, and on the toes in a straight line across (to preventingrown
toenail -a condition in which edges of toenails push into the skin). After the
finishing of nails, the trimming scissors are dried with cotton wool moistened
with 70% ethyl alcohol or another disinfectant.
Hair care. The newborn infant's hair should be brushed daily with an
infant
112
brush or other soft-bristle brush. Do not use regular brushes meant for older
children or adults as they can be too harsh for the newborn infant's delicate
scalp. It is generally not necessary to apply oil or lotion to the scalp. A few
minutes of brushing the hair stimulates the scalp. It is not necessary to wash
newborn infant's hair daily. The hair can usually be washed about every 3 or 4
days and can be done after infant's bath.
5.3. Clamping, cutting and care of the umbilical cord
Current standards of cord care are based on the principles of asepsis,
the aim of which is to decrease the likelihood of cord infections. Current medical practices - washing hands before cord care, clamping the cord with sterile
clamps, and cutting it with sterile scissors or blade are based on the principle
of aseptic technique. They have led to a reduction in omphalitis, neonatal
tetanus and sepsis.
If a baby is kept with its mother (by rooming-in), the bacteria
colonizing the baby come mostly from its mother's normal skin flora and are
predominantly non-pathogenic.
To separate the newborn from the placenta, the cord must be always be
ligated or clamped at the baby's side prior to cutting, since leaving it untied
can cause excessive bleeding. Plastic cord clamps effectively close all vessels in
the umbilical cord and are easy to use (Fig. 44).
When the cord stops pulsating, the umbilical vessels are constricted but
are not yet obliterated. Therefore the cord has to be clamped tightly in order to
keep the umbilical vessels occluded and prevent bleeding.
The instrument used cuts through living tissue and vessels that are still
connected to the infant's bloodstream; it therefore needs to be sterile to avoid
infection.
When the cord is cut, the cord stump is suddenly deprived of its blood
supply. The stump soon starts to dry and turns black and stiff (dry gangrene).
Drying and separation of the stump is facilitated by exposure to air. The cord
normally falls off within 1 -3 weeks after birth.
A sterile and sharp instrument, such as a new razor blade or scissors, is
usually recommended for
cutting the cord.
The
recommended
length of the stump after
cutting is usually 2 or 3
cm.
Some
authors
recommend clamping the
cord 3-4 cm clear of the
abdominal wall to avoid
pinching the skin or
clamping a portion of the
gut which, in very rare Fig. 44. Newborn, showing one of the umbilical clamps.
instances, may be inside
the
cord.
113
Principles of the intersection and clamping the umbilical cord:
- washing hands with clean water and soap before delivery and again
before cutting and tying the cord;
- laying the newborn on a clean surface;
- cutting the cord with a sterile instrument.
Care of the cord stump
Clean cord care at birth and in the days following birth is effective in
preventing cord infections and tetanus neonatorum.
- At birth, hands should be washed with clean water and soap before
delivery, after any vaginal examination, and again before tying and cutting the
cord.The newborn should be laid on a clean surface (such as the mother's
abdomen) and the cord should be cut with a sterile instrument.
Clean cord care in the postnatal period includes washing hands with clean
water and soap before and after care, and keeping the cord stump dry and
exposed to air or loosely covered with clean clothes. If soiled, the cord should
be washed with clean water and soap (cleaning with alcohol seems to delay
healing). The napkin should be folded below the umbilicus. Touching the cord,
applying unclean substances to it and covering it with bandages should be
avoided.
Other practices that may reduce the risk of cord infection are the use of
24-hour rooming-in instead of nurseries in institutions and skin-to-skin
contact with the mother at birth to promote colonization of the newborn with
non-pathogenic bacteria from the mother's skin flora. Early and frequent
breast-feeding will provide the newborn with antibodies against infections.
- After discharge from the hospital, clean cord care is sufficient and an
antiseptic is not required as it delays healing and drying of the wound.
5.4. Giving eye, ear and nose drops
Giving eye drops.
Explain to a child what you are going to do before you start.
- Describe what you are doing as you do it.
- Speak in a calm, reassuring voice.
- Praise a child when you are done.
1. If the medicine is cool, warm it to body temperature.
2. Wash you hands carefully before giving the drops.
3. Read prescription label and directions carefully.
4. If the eye has drainage or crusts, wipe the eye from outer corner to
inner comer with a cotton ball and water. If both eyes are being treated, use a
separate cotton ball for each eye.
5. Have a child lie down on his or her back
6. To instill eye drops, pull the lower lid down by your thumb to expose
the conjunctival sac (Fig.45).
7. Rest your other hand against the child's forehead and hold the dropper
about 5cm from a child's eye.
8. Put prescribed number of drops inside the lower eyelid, not on the
114
eyeball. Do not touch the dropper to the eye.
9. It can be hard to open the eyelids of infants and young children. If so,
put the drop into the inner corner of the eye. When the child opens the eye, the
medicine will flow into it.
10. Instruct the patient to close his eyes gently, without squeezing the
lids shut. If you instilled drops, tell the patient to blink. If you applied ointment,
tell him to roll his eyes behind closed lids to help distribute the medication
over the surface of the eyeball. Use a clean tissue to remove any excess
solution or ointment leaking from the eye. Remember to use a fresh tissue for
each eye to prevent cross-contamination.
11.
Wash your hands.
To apply an ointment, squeeze a small ribbon of medication on the edge
of the conjunctival sac from the inner to the outer canthus (Fig.46). Avoid
touching the tip of the tube to the patient's eye. Then release the eyelid, and
have the patient roll his eye behind closed lids to distribute the medication.
Fig.45. Administration of eye drops.
eye
ointments
Fig. 46. Administration of
Giving ear drops.
Before using the drops, the container should be placed in the hand for a
few minutes. The patient should be placed on the side opposite the affected
ear. Then straighten the patient's ear canal to help the medication reach the
eardrum. For an infant or a child under age 3, gently pull the auricle down and
back because the ear canal is straighter at this age (Fig.47). For an adult, gently
pull the auricle up and back (see Fig.48). Avoid pacing the dropper inside the
duct. The patient must remain in the same position for a few minutes to
prevent the medication from coming out. The eardrops are of individual use.
Giving nasal drops.
This route is used in case of nasal obstruction. Lay child on back and tilt
head back, holding arms down if possible (you may need someone to help).
Gently hold baby's head with one hand and insert the dropper just inside the
nares and instill the prescribed number of drops in each nares as ordered (Fig.
49). Elevate the nares slightly by pressing with the thumb. Try not to touch the
nares with the dropper.
• Wash your hands.
• Record medication given and the patient's response.
• If using a Spray, the patient should be sitting up with the head titled
back. The tip of the bottle is placed just inside the nares aimed toward the midline of the nose. Squeeze the bottle while the patient inhales (Fig. 50). Instruct
the patient to maintain this position for approximately 5 minutes. This position
will allow the medication to maintain contact with the nasal mucosa. Leaning
forward may allow the medication to run out the nares.
• Teach the patient that decongestant sprays can cause increased heart
rate and blood pressure and rebound nasal congestion. Frequent use can
stimulate the sympathetic nervous system.
• Wash your hands.
Record
medication
given
and
the
patient's
response.
Fig. 49. Giving nasal drops
Fig. 50. Using a nasal Spray
5.5. Rules of using pocket and permanent inhalers
The application of pocket (metered dose inhaler) and permanent
inhalers becomes more widespread at the modern stage of treatment of sick
children. At the treatment of children with respiratory disorders the
inhalation introduction is not only pathogeneticaly conditioned, but it gives
fast therapeutic effect thanks to the direct effect on respiratory system. It is
needed to remember that respiratory function disorder in childhood leads to
hypoxic disturbances fast because of immaturity of cerebral structures.
Thereby the support of sufficient oxygenation for child with respiratory
disorders will help to avoid complications of central nervous system. The
technique of humid oxygen delivery and rules of using pocket and
permanent inhalers should be known and given by every doctor.
A metered-dose inhaler (MDI) is a handheld device that delivers a
measured dose of medication directly to the lungs. The medication is
usually in an aerosol
116
form. This medication is pushed out of the MDI and delivered straight to the
lungs by a chemical gas propellant.
These inhalers include a pressurized canister with measured doses of
medication inside (Fig. 51). Squeezing the top of the canister converts the
medication into a fine mist. Some metered-dose inhalers are breath actuated
and don't require to squeeze the
inhaler. Patient places lips on or
near the inhaler's mouthpiece to
Canisterinhale the mist.
The metered-dose inhaler
Plastic holder
has five parts:
1. the propellant,
Metering
valve 1
2. the metering valve,
3. the mouthpiece,
4. the canister containing the medication,
5. the medication itself.
A plastic holder usually
forms the frame of the MDI.
- Propellant with
drug suspension
»^
IS?
Mouthpiece
Aerosol
Fig. 51. The metered-dose inhaler
Rules of using pocket (metered dose inhaler) inhalers
I. Testing of inhaler.
Before the first application of inhaler or after an interruption in the use
more than one week take off the hubcap of cannon-bit, slightly pressing on
him on each side, well shake an inhaler and do one dispersion in air, to make
sure in his adequate work.
II. Using an inhaler (Fig. 52)
1. The inhaler should be shaken well before use (3 or 4 shakes).
2. Remove the cap.
3. Instruct the patient to breathe out, away from inhaler.
4. Then the patient brings the inhaler to mouth, places it in mouth
between teeth and closes mouth around it.
5. Have the person start to breathe in slowly, press the top of inhaler
once and keep breathing in slowly until have taken a full breath.
6. Have a patient hold breath for about 10 sec, and then exhale slowly
with pursed lips.
7. If it is needed a second puff, wait 30 sec, shake inhaler again, and
repeat steps 3-6.
8. Repeat for each "puff"ordered, waiting 5 min or as prescribed between
puffs.
9. Store
all
puffers
at
room
temperature.
117
В
l
L
в
1
r
f
f
a
. r
/ ....... *
в
- trv
m 1
'
*
в
J .Г
Fig 52. Using an inhaler
A spacer is a chamber that can be attached to a metered-dose inhaler (MDI)
(Fig. 53).The spacer chamber may
have a one-way valve that allows the
medication to be held in the chamber
before it is inhaled. This way patient
can inhale the medicine in one or
many breaths, depending on his
ability. A spacer is recommended for
use with most inhalers,
especially
those
that
contain
corticosteroids. Spacers also should
Fig 53. Using a spacer
be used by children, who may have
difficulty using a metered-dose
inhaler correctly. A dry powder inhaler (DPI) is not used with a spacer.
Using a steam inhalers
Steam inhalers help to relieve the symptoms of sore throat and sinus problems, coughs and colds, by warming and
moisturizing the airways; loosening and
softening
mucous,
and
reducing
inflammation.
In the inhaler the medicine is crushed,
warmed up and immediately allocated
through the tube at the end of which there is a
mouthpiece, placed to the mouth of the
patient (Fig.54). Duration of inhalation
Fig.54.Using a steam inhalers
is 5-10 minutes. A patient should breathe normally and let the steam particles
fully infiltrate respiratory passages. In case of inhalation, trunk and extremities
of a small child are fixed; the nose is directed to the tube of the inhaler. This
procedure is painless; nevertheless children are usually afraid of it and cry, that
may cause mother's anxiety and refusal of inhalation. The crying of the
118
child is not dangerous. Besides, during his/her crying the child makes a deeper
breath which promotes the penetration of medicine into the inner parts of
respiratory tract.
One of few contraindications of inhalation for the child of early age is
stenosis of the throat (the anxiety during the procedure may result in greater
edema of respiratory tract).
5.6. Oxygen therapy
Oxygen therapy is the administration of oxygen as a therapeutic
modality. Oxygen therapy benefits the patient by increasing the supply of
oxygen to the lungs and thereby increasing the availability of oxygen to the
body tissues.
Appropriate levels of oxygen are vital to support cell respiration. High
blood and tissue levels of oxygen can be helpful or damaging, depending on
circumstances. Hyperbaric oxygen therapy is the use of high levels of oxygen
for treatment of specific diseases. High levels of oxygen given to infants
causes blindness by promoting overgrowth of new blood vessels in the eye
obstructing sight. This is Retinopathy of prematurity (ROP). Administration of
high levels of oxygen in patients with severe emphysema and high blood
carbon dioxide reduces respiratory drive, which can precipitate respiratory
failure and death.
Oxygen first aid specifically refers to the use of oxygen in a first aid
setting. Oxygen will assist patients with hypoxia (low blood oxygen levels).
Care needs to be exercised in patients with chronic obstructive pulmonary
disease, especially in those known to retain carbon dioxide (type II respiratory
failure) who lose their respiratory drive and accumulate carbon dioxide if
administered oxygen in moderate concentration. However the risk of the loss
of respiratory drive are far outweighed by the risks of withholding emergency
oxygen, and therefore emergency administration of oxygen is never
contraindicated.
Types of Oxygen delivery devices
Nasal CPAP is also known as Continuous
Positive Airway Pressure. CPAP stands for
"continuous positive airway pressure." CPAP is
a treatment that delivers slightly pressurized
air during the breathing cycle. This makes
breathing easier for persons with obstructive
sleep apnea and other respiratory problems.
Nasal CPAP is given through a mask that is
Fig.55. Nasal Continuous
placed and secured over the person's nose or
Positive Airway Pressure
noseand mouth (Fig.55). Slight positive
pressure is used to increase the amount of air
breathed in without increasing the work of
breathing. Nasal CPAP is useful for children
with collapsible airways, small lung volumes,
or
muscle
weakness
that
make
it
difficult
to
breathe.
119
120
The oxygen bag is mainly used for
emergency use in hospital and as health care
product at home (Fig. 56).It should be
prepared beforehand (two hours) and kept in a
warm room. A clean pillow-case is put on the
I
bag, and the respirating funnel is washed in
warm water. The funnel is placed 1-3 cm from
the mouth of the infant, the stopcock is
opened cautiously, and the bag is pressed
gently with the hand, so that a Fig.56.
Configuration of small stream of oxygen slowly
emerges.
the oxygen bag
Oxygen is given over one-hour intervals for 2-3 min. From one to four bagfuls may be given in 24 hours. However, one must never forget that thorough
airing of the room and taking the child outside may often be an adequate
substitute for the inhalation of oxygen.
pressed gently with the hand, so that a small stream of oxygen slowly
emerges. Oxygen is given over one-hour intervals for 2-3 min. From one to
four bagfuls may be given in 24 hours. However, one must never forget that
thorough airing of the room and taking the child outside may often be an
adequate substitute for the inhalation of oxygen.
Low-Flow Devices
Low-flow systems deliver oxygen at flows that are less than the patient's
inspiratory flow rate (i.e, the delivered oxygen is diluted with room air) and,
thus, the oxygen concentration inhaled may be low or high, depending on the
specific device and the patient's inspiratory flowrate.
The nasai cannula (NC) is a thin tube with two small nozzles that protrude
into the patients nostrils (Fig. 57). The rest of the tubing wraps around the
head. It can only comfortably provide oxygen at low flow rates, 0.25-6 I per
min (LPM), delivering a concentration of 24-40%. Flow rates greater than 4 I per
mi can cause discomfort and dry out
the nasal passages and should also be
used with a humidifcation system.
Patients prefer cannulas over masks
because they are less confining and do
not interfere with eating or talking.
Cannulas should be used with caution
on patients with irregular breathing
patterns because the percentage of
oxygen reaching the lungs varies with
the rate and depth of respirations.
Fig. 57. A patient with nasal cannula
121
Nursing skills in supplying oxygen with the Nasal Cannula
Supplies and Equipment
Oxygen source, gloves, flowmeter, nasal cannula and tubing, humidifier
and sterile water
Procedure
1. Gather supplies. Wash hands. Wear gloves.
2. Explain procedure to patient.
3. Prepare the oxygen equipment:
a. plug the flowmeter into the wall outlet or oxygen tank;
b. attach the humidifier to the flowmeter;
c.
fill
the humidifier with sterile water;
d. attach cannula with connecting tubing to adapter on humidifier.
Humidification prevents drying of nasal mucosa. Agency policy dictates
whether low flow oxygen (3 I or less) requires humidification.
4. Adjust flowmeter setting to the ordered flow rate. Check that oxygen
is flowing out of prongs. Rate via cannula should not exceed 6 L/ min (LPM).
Higher rates may cause excess drying of nasal mucosa.
5. Insert prongs into patient's nostrils. Adjust tubing behind ears and
slide plastic adapter under chin until comfortable. Proper position allows
unobstructed oxygen flow and eases the patient's respirations.
6. Encourage patient to breathe through nose rather than mouth. More
oxygen is inhaled into trachea and less likely to be exhaled through the mouth.
7. Assess patient's comfort level. Leave call signal within reach. Anxiety
increases the demand for oxygen.
8. Wash hands.
9. Place "No Smoking" sign at entry into room. Sign warns patient and
visitors that smoking is prohibited because oxygen is combustible.
10. Dispose of gloves and wash your hands. Document the procedure
and record the patient's reaction.
11.Check oxygen setup including water level in humidifier. Clean cannula
and assess nares at least every 8 h. Sterile water needs to be added when level
falls below line on humidification container. Nares may become dry and
irritated and require use of a water-soluble lubricant.
2. The simple face mask (SFM) is a basic mask used for non-life-threatening conditions but which may progress in time, such as chest pain (possible
heart attacks), dizziness, and minor hemorrhages. It is often set to deliver
oxygen
between
5-15
LPM.
122
The final oxygen concentration
delivered by this device is dependent
upon the amount of room air that
mixes with the oxygen the patient
breathes. The general oxygen concentration is between 35% and 50%.
The simple face mask is a transparent
mask with a simple nipple adapter. It
is fitted over the nose, mouth, and
chin (Fig.58).
H
Fig. 58. A patient wearing a simple face
mask
Supplies and Equipment
Oxygen mask, source of oxygen, gloves
Nursing skills in supplying oxygen with a simple mask
Procedure
1. Wash your hands and wear gloves.
2. Explain the procedure and the need for oxygen to the patient.
3. Attach the humidifier to the threaded outlet of the flowmeter or
regulator.
4. Connect the tubing from the simple mask to the nipple outlet on the
humidifier.
5. Set the oxygen at the prescribed flow rate.The oxygen must be flowing
before applying the mask to the patient)
6. To apply the mask, guide the elastic strap over the top of the patient's
head, bring the strap down to just below the patient's ears. This position of the
elastic will hold the mask most firmly.
7. Gently, but firmly, pull the strap extensions to center the mask on the
patient's face with a tight seal. The seal prevents leaks, as much as possible.
8. Make sure that the patient is comfortable.
9. Remove and properly dispose of gloves; wash your hands.
10.
Document the procedure and record the patient's reactions.
11.
Check the patient periodically for depressed respirations or
increased pulse.
12. Check for reddened pressure areas under the straps.
N.B! The simple mask requires a minimum oxygen flow rate of 6 LPM to
prevent carbon dioxide buildup.
3. The Partial rebreathing mask is a simple mask with a reservoir bag.
Oxygen flow should always be supplied to maintain the reservoir bag at least
one third to one half full on inspiration, usually 5-15 LPM. At a flow of 6-10 L/
min the system can provide 40-70% oxygen.
Nursing Skill
Supplies and Equipment
Mask, oxygen source, gloves
Procedure
1.
Wash
your
hands
and
wear
gloves.
123
2. Explain the procedure and need for oxygen to the patient.
3. A humidifier is not necessary and often is not recommended. The
humidifier can restrict enough airflow so the device cannot keep up with the
patient's demand. Attach to oxygen source.
4. Set the oxygen flow rate at 12 to 15 LPM.
5. Place your finger inside the mask over the hole that leads out of the
bag. This will cause the bag to inflate with oxygen.
6. Place the mask over the bridge of the nose and bring the mask down
over the chin. Guide the elastic strap over the head and secure as with the
simple mask.
7. Ask the patient to take a few breaths, and observe to make sure that
the bag deflates with each inspiration, but not to less than one third full. If the
bag does not inflate and deflate, it is either malfunctioning or not correctly
sealed.
8. Reduce or raise the flow rate to the minimum possible level at which
proper deflation occurs (but not less than 6 LPM). Regulation of the flow rate is
based on the breathing of the patient, as related to the bag's deflation and
inflation.
9. Make sure that the patient is comfortable. Put the call signal within the
patient's reach before leaving the room.
10.
Remove and dispose of gloves; wash your hands.
11. Document the procedure, recording the patient's reactions.
12. Check the patient periodically.
High-Flow Devices
High-flow systems deliver a prescribed gas mixture at flowrates that
exceed patient demand.
1. The non-rebreather mask (NRB) is similar to the partial rebreathing
mask except it has a series of one-way valves. One valve is placed between the
bag and the mask to prevent exhaled air from returning to the bag (Fig. 59).
There should be a minimum flow of 10L/min. The delivered oxygen of this
system is 60-80%, depending on the oxygen flow and breathing pattern.
Venturi mask- the high-flow mask provides the most reliable and
consistent oxygen enrichment of all the facial devices (Fig. 60). The Venturi
mask can be identified by the presence of a hard plastic adapter, with large
"windows" on the sides of the adapter.
Venturi masks offer specific oxygen concentrations in the 24% to 50%
range.The exact concentration offered varies with the manufacturer. By
drawing room air in through the windows, the Venturi mask mixes a low flow
of gas (oxygen) with a high flow of room air. This produces a high flow of gas
to
the
patient,
with
a
specific
oxygen
concentration.
124
I щ-
ВL
Fig. 59. Adult non-rebreathing mask with
oxygen tubing, reservoir and two side valves
Oxygen
concentrations
are
Fig. 60. Venturi masks
changed by changing adapters, by
changing the window opening, or by
combining these changes. Because of
the number of possibilities, the nurse
should refer to the directions accompanying the mask. The directions also
specify the oxygen flowmeter setting to use for each desired oxygen
percentage. The respiratory care personnel should be consulted as well.
Providing Oxygen With the Venturi Mask
Supplies and Equipment
Mask, oxygen source, gloves
Procedure
1. Wash your hands and wear gloves.
2. Explain the procedure and need for oxygen to the patient. Attach the
wing nut and tailpiece to the threaded outlet of the flowmeter.
3. Connect the tubing from the Venturi mask to the tailpiece. Attach to
oxygen source.
4. Attach the appropriate adapter or set the window openings, in
accordance with the manufacturers directions for the prescribed percentage of
oxygen.
5. Set the flowmeter to the manufacturers recommended flow rate for the
prescribed oxygen percentage.
6. Place the mask over the bridge of the patient's nose and then down
onto the chin. Guide the elastic strap over the patient's head and secure as for
the simple mask.
7. Make sure the patient is comfortable. Put the call signal within the
patient's reach.
8. Place the bed linen so as not to cover the Venturi adapter. The linens
could plug the windows and disrupt the concentration of oxygen desired)
9. Remove and dispose of gloves; wash your hands.
10.
Document the procedure, recording the patient's reaction.
11.
Check the patient periodically for depressed respirations and
increased pulse.
12.
Check
for reddened pressure areas under the straps. The
straps, when sung, put pressure on the underlying skin areas.
125
Note!
- Humidifiers should not be used with Venturi masks. (Significant
backpressure may cause activation of the safety pressure valve on the
humidifier and may cause some humidifiers to burst. In addition, the large
amount of room air used by these devices humidifies the gas adequately.
- The windows must remain exposed to room air. The oxygen flow can
be occluded if the windows or the end of the adapter are covered by sheets or
blankets. This would alter the oxygen concentration.
Resuscitation/Specialized Devices\
The bag-valve-mask (BVM) is used for patients in critical condition who
are either breathing extremely inefficiently, or not breathing at all (respiratory
arrest). An oxygen reservoir bag is attached to a central cylindrical bag,
attached to a valved mask that administers almost 100% concentration oxygen
at 8-15 Ipm (Fig. 61). The central bag is squeezed manually to deliver a
"breath" to the patient, or assist them in inspiration by overcoming airway
resistance or thoracic constriction. This is the standard administration method
for acute respiratory distress or respiratory arrest.
The pocket mask is a small device that can be carried on one's person
(Fig. 62). It is used for the same patients who the BVM is indicated for, but
instead of delivering breaths by squeezing a reservoir, the care provider must
exhale into the mask. Exhaled air from the provider can provide up to 16% oxygen to the patient, or higher if used with supplemental oxygen.
Fig. 61 .The bag-valve-mask
Fig. 62. The pocket
mask
Tests for self-training Q1. At what age is it
reasonable to start training the child to teeth brushing?
A. 7 years.
B. 3 years.
C. 5 years.
D. 10 years.
E. after the permanent teeth have erupted.
Q2. The first hygienic bath for newborn is conducted:
A. Right after the discharge from the maternity hospital.
B. After falling-away of the umbilical cord (7-10 days).
C. At achievement of body weight of 4,000 g.
D. Up to 6 months the child is wiped with sterile (distilled) water.
Q3. During the use of a pocket inhaler the case of the inhaler should be
held:
A. Only vertically.
B.Only horizontally.
126
C. The position of the inhaler does not matter and depends on the child's
body position.
Q4. Daily care of the eyes of a newborn consists in:
A. Ashing of the eyes after every feeding.
B. Washing with boiled water as necessary.
C. Washing with flowing water as necessary.
D. Washing of the eyes from the external corner to the bridge of the nose.
E.Washing of the eyes from the bridge of the nose to the external corner.
Q5. The indication for oxygen therapy is:
A. Cerebral contusion.
B. Cannulation of central veins.
C. Respiratory insufficiency.
D.Diabetes mellitus.
E. Gastroduodenitis.
Q6. What is the best method of the umbilical cord care at the immediate
neonatal period?
A. The use of 1 % brilliant green.
B. The use of topical antibiotics.
C. The umbilical cord is not treated.
D. The use of 3% hydrogen peroxide.
E. The use of 5% iodine solution.
Q7. The first suckle of the newborn should take place in:
A. 30 min.
B. 2 hours.
C. 10 min.
D. 45 min.
E. 60 min.
Q8.The main shortcoming of ultrasonic inhalers are:
A. Heightened humidity of aerosol medicine.
B. Overheating.
C.
The introduction of pathogenic flora is possible.
D. Changing of composition of used medicines. Q9. A nose care for the
healthy infants:
A. Is conducted once a week.
B. Is conducted twice a day (in morning and evening).
C. Is conducted after every feeding.
D.Is conducted with a dry sticks.
E. Is conducted by flagellum, moistened in physiological solution.
Q10. The temperature of water for hygienic bath for 2 months old baby
should be:
A. 40-42 °C.
B. 36.5-37 °C.
C. 38-39 °C.
D. 32-34 °C.
E. depends on season.
Correct answers: Q1 -B; Q2 -B; Q3- A; Q4- D; Q5 -C; Q6 -C; Q7- A;
Q8 - C; Q9 - E; Q10 - В
Chapter 6.
DUTIES OF THE NURSE ON PROVIDING THE FEEDING OF CHILDREN OF THE FIRST
YEAR OF LIFE
6.1. The technique of breast feeding
"There is no better nutrition for infants than breastfeeding"
127
WHO
The Baby-Friendly Hospitals promotes, protects, and supports breastfeeding through the ten steps to successful breastfeeding for hospitals, as
outlined by UNICEF/WHO.
The Ten Steps to Successful Breastfeeding are:
1. Written breastfeeding policy that is routinely communicated to all
health care professionals.
2.Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant mothers about the benefits and management of
breastfeeding.
4. Help mothers initiate breastfeeding within 1/2 h of delivery.
5. Show mothers how to breastfeed, and how to maintain lactation even if
separated from their infants.
6. Give newborn infants no food or drink other than breast milk unless
medically indicated.
7. Practise'rooming-in' (allow mothers and infants to remain together), 24
h a day.
8. Encourage unrestricted breastfeeding.
9. Give no artificial teats or pacifiers (dummies) to breastfeeding infants.
10. Foster the establishment of breastfeeding, support groups and refer
mothers to them on discharge from hospital or clinic.
Immediately following delivery, the healthy infant should be placed on
the mother's chest or upper abdomen. The infant can be dried by delivery room
personnel at the bedside to help lessen evaporative heat loss but at this point,
skin-to-skin contact between the mother and infant can facilitate
breastfeeding. Early skin-to-skin contact improves maternal-infant bonding.
Further, infants who have early maternal contact have been found to nurse
more effectively at the first feeding and, in some cases, if the baby is left alone
on the mother's chest, it has crawled spontaneously to the breast and suckled.
Breast-feeding is feeding of a baby with breast milk directly from the
breast or from a bottle after expressing the milk with a pump. Breast milk provides the best nutrition for a baby.
All major professional medical organizations, which focus on children,
recommend breast-feeding for at least the first year of a baby's life. Medical
experts say that mother's milk is the best nutrition for a child particularly till
the age of six mo. Other foods, such as cereal, are then gradually introduced
while continuing the breast-feed. Newborns are usually fed "on demand", or
approximately every 3 to 4 h.
When 0 to 3-4-month-old infants are provided with the appropriate sensory
input, ("skin to skin" or firm contact with the mothers' body and breast) they
instinctively search for the breast by lifting their heads and thrusting the chin
and mouth forwards, which in turn has the effect of tilting the head backwards.
This "Instinctive" position, or posture, anatomically matches the processes
required for good attachment and the "suck-swallow-breathe" cycles that
compose breast-feeding.
128
Positions for feeding (Fig. 63)
Mothers feed infants lying in beds during first days after the delivery,
later - sitting on the comfortable high chair.
- Assist the woman and infant in the breast-feeding process.
- Have the mother wash her hands before feeding to help prevent
infection.
- Encourage the mother to assume a comfortable position, such as
sitting upright in the bed or in a chair, or lying on her side.
- Have the woman hold the baby so that he or she is facing the mother.
Assist the mother into a comfortable position. (She will be in the same position
for about 20 min.)
There are many positions and ways in which the feeding infant can be
held. This depends upon the comfort of the mother and child and the feeding
preference of the baby - some babies tend to prefer one breast to another.
Common positions for holding the baby are thecradle hold (Fig. 63 A),
when the baby is held with its head in the woman's elbow horizontally across
the abdomen, with the woman in an upright and supported position.Crosscradle hold (Fig. 63 B): as above but the baby is held with its head in the
woman's hand. The cross cradle hold is especially useful for young infants who
have not figured out how to breastfeed yet. It's called the cross cradle because
a mother uses her left arm to hold the baby while he nurses on the right breast.
To feed from the left breast, mother will hold the baby with her right arm and
the right hand will position the baby's head onto the left breast.The football
hold (Fig. 63 C), in which the woman is upright and the baby is held securely
under the mother's arm with the head cradled in her hands. Lying on the side
(Fig. 63 D) with the baby lying on his/her side facing the mother. Australian
hold is sometimes recommended when a mother has too much milk or the flow
of milk is too fast.
- There are two ways to do the Australian Hold:
- reclined position: A mother is lying in a reclined position or flat on her
back and place baby on top of facing towards her. Position baby so that his/
her head is level with mother's breast.
- sitting up: (Fig. 63 E) A baby sits on mother's lap, facing her, and
straddling on one of her legs. Mother holds the back of the baby's neck to
support his head while he latches-on and drinks. Mother may use pillows if
baby is not tall enough to reach a breasts. Because baby is sitting up, gravity
helps the milk find its way down baby's throat. Also because baby's mouth is
level with mother's breast, the milk does not come gushing down as quickly.
129
-с'
88
Fig.63. Common feeding positions:
A) Cradle hold;
B) Cross-cradle hold;
C) Football hold (underarm position);
D) Side-lying position;
E) Australian
'г
-ь.
- Teach the woman to bring the baby close to her, to prevent back,
shoulder, and arm strain.
Have the woman cup the breast in her hand in а С position, with bottom
of the breast in the palm of her hand and the thumb on top.
- Have the woman place her nipple
against the side of the baby's mouth, and
when the mouth opens, guide the nipple
and the areola into the mouth. The baby
should latch on so that as much of the
areola as possible is in his mouth (Fig.64).
Milk glands
If the baby has latched on to the nipple
only, take the baby off the breast by
putting the tip of the mother's finger in
Tongue Areola
the corner of the baby's mouth to break
the suction, and then reposition on the breastFig.64. Proper latching on
to prevent nipple pain and trauma.
Correct positioning and technique for latching on can prevent nipple
soreness and allow the baby to obtain enough milk.
- Encourage the woman to alternate the breast with which she begins
feeding at each feeding to ensure emptying of both breasts and stimulation
108
for maintaining milk supply.
- Advise the mother to use each breast at each feeding. Begin with
approximately 10min at each breast, then increase the time at each breast,
allowing the infant to suck until he or she stops sucking actively. Pinning a
safety pin to the bra as a reminder of which breast to start with at the next
feeding is helpful.
- Have the mother breast-feed frequently and on demand (every 2 to 4
h) to help maintain the milk supply.
- Have the mother air dry her nipples for approximately 15 to 20 min
after feeding to help prevent nipple trauma.
- Have the mother burp the infant at the end of the feeding to help
release the air in the stomach and to make the infant less fretful.
If there is a doubt, how sufficiently a child sucks out milk from a
mother's chest, it is needed to conduct the control feeding.The child wrapped
up and prepared for this purpose to feeding is weighed before and after
feedings. Difference in weight between the second and first weighing will be
the index of amount of milk, which was sucked out by a child. If a child
sucked out milk less than it is needed, lure a child with the strained off milk of
mother or feeding formulas. The control feeding must be conducted 3-4
times per a day.
6.2. The technique of feeding
children from a bottle in artificial
feeding
Formula feeding is the alternative to breast feeding. When feeding,
baby's head should be slightly
raised, resting in the bend of your
elbow, close to you. Be sure to hold
the bottle so that the nipple is always
full (Fig.65). This will prevent the
baby from swallowing too much air.
Fig. 65. A baby fed from a botle
Watch the level of formula and also
the teat, which shouldn't flatten
totally. If it does, pull it out of her
mouth slightly to break the vacuum and then give it back to her. Never prop
the bottle.
Steps to Prepare Infant Formula
Commercial infant formula may come in three different forms:
ready-to- feed, concentrated liquid and powder. Powder formula is the most
commonly used and economical form.
Wash your hands with soap and water before you begin. Wash all the
bottles and equipment in hot soapy water. Rinse well with hot water.
Sterilize all bottles and equipment for baby's first three or four months
of life. To sterilize: cover the containers and equipment completely with water
131
and boil for five minutes. Cool. Remove with sterile tongs. Disposable bottle
liners do not require sterilization. For older babies, everything can be washed
132
in hot soapy water and rinsed well or cleaned in the dishwasher. Modern
bottles are difficult to sterilize in boiling water because they tend to float.
Bottles were originally composed of glass which was dangerous when babies
learned to feed themselves and held the bottle. Mainly for cost reasons,
modern bottles are unbreakable plastic. Since bottles have to be made to
withstand the heat of sterilization, the bottle can also withstand the heat of
dishwashers and are dishwasher-safe. While bottles were traditionally
sterilized in the past, unless there are infant health concerns, or concerns
about water contamination, the current recommendation is that baby bottle
sterilization can be replaced by cleaning with hot soapy water.
Mix. Follow the mixing instructions on the label to the letter. Preparing a
single feeding at a time is recommended, but you can prepare up to a
24-hour supply of infant formula at one time. The water for formula should
be boiled for 5 min then cooled. The formula label gives directions on how
much concentrated liquid or powder to add to the water. Measure exactly. If
too much water is added baby will not get enough nutrients. If too little water
is added baby may become dehydrated.
Before even let baby suck, make sure the formula is coming through the
nipple at the right speed. If baby seems to be fussing and sucking very hard,
it may not be flowing fast enough. If baby is gulping and sputtering, it's probably flowing too quickly.
You can test the flow of formula by turning the bottle upside down. You
should see just a few drops come out of the nipple. If you are using a powdered formula, be sure that no lumps of powder are clogging the nipple.
Find a comfortable position and settle baby in with you. Cradle and support his head. Make sure you keep his head above his tummy to keep baby
from choking or liquid draining into his ear and causing an infection. The best
part of feeding is you and your baby being close.
Store. Prepared formula should be either fed to baby or refrigerated
immediately. If baby does not finish all the formula in the bottle during a
feeding, discard what is left in the bottle. Prepared bottles of formula can be
stored up to 24 h in the refrigerator. The formula should never be left at room
temperature for longer than-1 h. Bacteria that can make baby sick grow
quickly in warm formula.
6.3. A tube feeding
Tube feeding can be initiated for a wide variety of reasons. Premature
infants under the gestational age of 33 weeks have not reached the stage of
development where strong sucking and swallowing patterns can support oral
feedings. Some children have such severe respiratory or cardiac problems
that they do not have the energy to suck and swallow. Because the respiratory
system and the feeding system use the same passageway in the upper portion
of the pharynx, difficulties with swallowing or breathing can cause a child to
aspirate, or draw food or liquid into the lungs rather than into the esophagus.
133
Other children may lack the neurological coordination required to organize
the collection and movement of food in the mouth, and to propel it to the
back of the tongue and the pharynx for swallowing. Sucking and swallowing
may be very slow or very uncoordinated, and the child might be unable to
take in enough calories before becoming exhausted. Still other children experience severe gastrointestinal difficulties that cause food to be refluxed
and vomited. Surgical procedures to prevent reflux may increase the
discomfort of swallowing and result in a reduced desire to eat.
Tubes can be divided into two general categories: those that are
inserted through the oral-pharyngeal area (i.e. nasogastric tubes, orogastric
tubes), and those that are not (i.e. gastrostomy tubes, jeujenostomy tubes).
A feeding tube is a thin, soft, lexible plastic tube placed through the
nose (NG) or mouth (OG) into the stomach. Fluids and special feed can be
given down this tube to help prevent dehydration and weight loss. These
tubes are used to provide feedings and medications into the stomach until
the baby can take food by mouth.
Nasogastric tube feeding
When preterm or low birth weight infants are too immature or unwell to
suck feeds they can receive their milk through a feeding tube passed via either the nose
or the mouth
(Fig.66). Although tubes placed via
the nose may be
more stable and less prone to
displace than
tubes passed via the mouth, there
is concern that
nasal tubes will partially obstruct breathing.
Implementation
of
Fig. 66 Nasogastric tube feeding
nasogastric tubes
1. Put on gloves.
2. Position the patient.
3. Place a protective pad/towel on the patient's chest as well as provide
the patient with a basin to minimize contact with aspirated gastric contents.
4. Using the NG tube as a measuring device determine the length of the
NG tube to be passed by measuring the length from:
a. nose to earlobe;
b. earlobe to xiphoid process;
5. Add the measurements together and mark this total distance with a
small piece of tape.
6. Inspect both of the patient's nostrils for patency. Have the patient
blow nose if able.
7. Lubricate the end of the lavage tube with the water-soluble lubricant
or
anesthetic
ointment.
134
8. Insert the NG tube through the nostril to the nasopharynx slowly and
gently; direct the tube through the nostril aiming down and back. Introduce
the tube until the selected mark (indicated by the tape) is reached.
9. Verify NG tube placement in the stomach by two of the following:
a. aspirating gastric contents with the irrigation syringe;
b. while listening over the epigastrum with a stethoscope quickly instill a
30cc of air with the irrigation syringe. Air entering the stomach will produce a
"whooshing" sound;
c. coughing, cyanosis or choking may indicate that the NG tube has
passed through the larynx.
10. If unable to positively confirm that the NG tube has been placed is
in the stomach the tube must be removed immediately and re-attempted.
11. To deter the NG tube from dangling and possible dislodgment:
a. curve and tape the tube to the patient's cheek to prevent unnecessary
tugging on the nostrils. Attach the tube to the patient's gown. (Do not tape to
the patient's forehead as this will put pressure on the nares).
b. wrap a small piece of tape around the tube near the connection
creating a tab. Loop a rubber band in a slip knot near the connection and pin
to the patient's gown.
12/ After securing the lavage tube nasally or orally and making sure the
irrigant inflow tube on the lavage setup is clamped, connect the unattached
end of this tube to the lavage tube. Allow the stomach contents to empty into
the drainage container before instilling any irrigant.This confirms proper tube
placement and decreases the risk of overfilling the stomach with irrigant and
inducing vomiting. If you're using a syringe irrigation set, aspirate stomach
contents with a 50-ml bulb or catheter-tip syringe.
13. If ordered, remove the lavage tube.
Special Considerations in Children
- Children have smaller stomachs; therefore smaller amounts are given.
- Feedings may take longer.
- If stomach is too full, formula may leak around, child may vomit or
spit up; child may act "colicky".
- Decompression may be needed to relieve gas.
- Include child in mealtimes with other children.
- Use pacifier to provide sucking and to promote teething.
- Protect the tube from being pulled out.
- Because a smaller tube is used, it clogs easier.
The disadvantages of NG feeding include nasal or esophageal irritation
and discomfort (especially if used long-term); increased mucus secretion;
and partial blockage of the nasal airways. Nasogastric feeding may contribute
to recurrent otitis media and sinusitis. With infants, NG feeding can decrease
the suck/swallow mechanism. Two additional disadvantages are the
possibility that the tube will perforate the esophagus or the stomach and the
possibility that the tube will enter the trachea, delivering formula into the
lungs. If formula enters the lungs, severe or fatal pneumonitis can result;
135
therefore, it is essential to confirm that the NG tube is in the stomach before
feeding begins
Tests for self-training
Q1 .The length of nasogastric tube for a child feeding is measured:
A. From a nasal bridge to the xiphoid process.
B. From a tragus to the xiphoid process.
C. From a nasal bridge to tragus and to the navel.
D. From a nasal bridge to an ear-lobe and to the xiphoid process.
E. From a chin to the navel.
Q2. The early feeding of child provides:
A. Colonization of skin and mucous membranes of child with the
pathogenic microflora.
B. Regulation of ovulatory cycle of nursing mother.
C. Regulation of newborn's unconditioned reflexes.
D. Early appearance of lactational crisis.
E. Increase of terms of falling off the umbilical cord.
Q3. The temperature of a mixture for artificial feeding of a child should
be: A. 36°C
В. 37°C
C. 40°C
D. 34°C
E. 41 °C
F. depends on the season
Q4.The most convenient position for feed twins together is:
A. The'lying down' position.
B. Cradle hold position.
C. Cross-cradle hold position.
D. Football hold (underarm position).
E. Australian hold position.
Q5. First feeding of a healthy child is recommended be carried out:
A. In the first 30 minutes after the birth.
B. In the first days after the birth.
C. In the first 2 hours after the birth.
D. In the first 60 min after the birth.
E. In the first 2 days after the birth.
Q6. A child aged 2 months is bottle-fed. The number of feeding should
be:
A. 5 times.
B. 6 times.
C. 7 times.
D. 10 times.
E. no more than 5 times.
Q7. A breast-fed baby has rhinitis. What recommendations should you
give to mother?
A. To instill nasal drops before feeding.
B. To
stop feeding every 2-3 min.
C. To
feed a baby with expressed breast milk from a bottle.
D.Technique of feeding stays in ordinary term.
E. To feed a baby with expressed breast milk from a spoon. Q8. In a
breast-fed baby of 4 months mother should:
A. To put a baby only to one breast by day.
B. Alternate right and left breast by day.
136
C. To put to both breasts during one feeding.
D. Necessarily to wash breasts with boiled water before feeding.
E. Necessarily to strain off milk after every feeding. Q9. Which
statement is incorrect:
A. The first feeding is carried out in the first 30 min after birth.
B. A child has well developed sucking and swallowing reflexes.
C. Not to limit the water intake of child.
E. Before feeding mother must wash
breasts. Q10. Introduction of feeding up
means:
A. Feeding from a bottle.
B. To
give feeding up before breast-feeding.
C. Try to give feeding up from a little spoon.
D. To give feeding up not early than 30 min after breast-feeding. Correct
answers: Q1- D; Q2 - A; Q3 - B; Q4- D; Q5 - A; Q6- B; Q7 -D;
Q8 -B; Q9 -C;Q10-C.
FINAL MODULE ASSESSMENT
The basic deontological principles of work of a nurse with children
and their relatives.
Basic functional duties of a nurse in a children's hospital.
Medical documents. The rules and ways of filling in the documents by
a nurse.
Rules for the calculation and keeping of drugs.
Writing out a prescription, calculation and keeping of poisonous,
narcotic and potent medicines.
Basic functional duties of a junior nurse in a children's hospital.
Thermometry, measuring of arterial pressure, pulse and respiratory
rate in children of different age.
Giving of an enema to children of different ages.
Techniques of application of mustard plasters, a hot-water bag and
an ice pack in children.
Taking of urine for examination by the methods of Zimnitskiy,
Nechiporenko, Addis sediment count; their diagnostic value.
A technique of breast feeding.
A technique of artificial feeding of children using a bottle.
A technique of the mixed feeding of children.
Use of hygienic baths in infants. Intimate washing of girls.
A technique of the care of the mouth, eyes and nose; treatment of
the umbilical cord.
Instillation of drops into the eyes, ears and nose.
A technique of the anthropometrical measurement (height, weight,
head and chest circumference) in children of different ages.
137
LIST OF PRACTICAL SKILLS
1. Rules of giving out pills and mixtures for oral use by children of a
certain age.
2. To measure patient's (child's) body temperature and fill in a
temperature chart.
3. To determine the pulse and blood pressure and describe their
properties.
4. To show the method of swaddling a newborn.
5. To prepare the proper facilities and show the method of feeding a
child of the first year of life.
6. To prepare the proper facilities and show the technique of the oral
hygiene, eye, ear and nose care of an infant.
7. To prepare the proper facilities and show the method of a hygienic
bath and intimate washing of children according to their age and sex.
8. To show the technique of a hypodermic injection.
9. To show the technique of an intramuscular injection.
10.
Calculate
a dose of an antibiotic and dissolve it in
case of need.
11. To prepare a dropping bottle for an intravenous infusion. To prepare
necessary solutions for a parenteral introduction and show a correct
utilization of syringes after their use.
12.To show a technique of giving eye, ear and nose drops.
13.To show a technique of collection of a nose and throat swab.
14. To describe a cleansing enema and show a technique of its use in
children of different ages.
15. To prepare the proper facilities and show a technique of gastric
lavage in children.
16. To prepare the proper facilities and show a technique of giving a
medical enema to children of different age.
17.To show a technique of an intramuscular injection.
18. To prepare the proper facilities and show the method of
anthropometrical measurement (height, weight, head and chest
circumference) in children of different ages.
19.To show a technique of application of hot compresses to the ears.
20. To show a technique of a mustard plaster application.
21. To show a technique of moistened oxygen use.
DAIRY
Of PRACTICAL TRAINING IN CHILDREN'S HOSPITAL FOR NURSING
for З^-уеаг medical students, group No ______
(first and second names)
Place of the training:
Department: _____________________________
Medical establishment:____________________
138
Date, working
hours
Action
Teacher's
signature
Total report Of practice in
Nursing by a student of the 3rd year of the Medical Faculty,
group No
139
(first and second names)
Place of training: Department: Medical establishment: From till 20 yr
№
Practical skills
1.
Filling in documents of an attendant nurse in
pediatric department.
Measurement and recording of BP and pulse rate in
children
2.
3.
Measurement and recording of the body temperature
4.
Investigation of the respiratory function in children
5.
Oral administration of medicines
6.
Giving of subcutaneous injections
7.
Giving of intramuscular injections
8.
Giving of intravenous injections and infusions
Preparing instruments for sterilization and carrying
out disinfections
9.
The work
performed
10. Collection of a nose and throat swab in sick children
11.
Giving enemas to children of different age
12. Stool and urine specimen collection for different
investigations in children.
13.
Gastric lavage in children
14.
Application of compresses
15.
Application of mustard plasters, hot-water bag, ice
pack
16. The technique of applying infants to the breast in
breast-feeding.
17.
Artificial feeding of babies with help of a bottle
18.
Hygienic and medicated baths in infants
19.
Mouth, eyes and nose care
20.
Umbilical cord care
Anthropometrical measurement in children of
different ages
21.
22
Others (indicate)
Teacher'signature.
140
Bibliography
1. Behrman R. E. Nelson textbook of pediatrics. - Bangalore, India.: W.B.
Saunders Company, 1993. - 538 p.
2. Behrman R. E., Kliegman R.M. Nelson essentials of pediatrics.Philadelphia, London, Toronto, Montreal, Sydney, Tokyo.- W.B. Saunders
Company, 1990.- 647 p.
3. Kapitan T. Propaedeutics of children disease and nursing of the child:
Textbook for students of higher medical educational institutions - Vinnitsa:
The State Cartographical Factory, 2006. - 736 pp.
4. Kovalyova 0. Medical ethics. -Kharkiv, 2001. -128p.
5. O.Tiazhka. Pediatry.Guidance Aid.- Kyiv. - Medicine. - 2007. - 158p.
6. Fjoklin V.A, Sirenko T.V., Frolova T.V., Kojemiaka A.I., Plachotna O.N.Introduction to children diseases. Part I. Practical manual for foreign
students.- Kharkiv. -2005 - 227p.
7. Rosdahl, Caroline Bunker. Textbook of basic nursing. - Philadelphia.
Lippincott
Сотр.
-1995,6th
ed.
-1518p.
141
Appendixl
Ministry of health
Ukraine
Name
establishment
MEDICAL FORM N003/0
Approved by the order of Ministry of health of Ukraine
of
of
26.07.99
N184
MEDICAL CARD N _____
Date
(arrival time)
Discharging date
OF HOSPITAL PATIENT
Department
Hospitalization
(date, mo, yr)
In current year has
been hospitalized
(date, mo, yr)
О first
Оrepe
atedly
total times
The number of bed days spent at hospital __________________________
Blood group ____________________ Rh-factor ______________________________ RW_
High sensibility or drug intolerance ___________________________
(date, mo, yr)
(drug name, character of drug side effect)
1. Family name, first name of child
2.sex: male-1, female-2 | 13. Age_
4. Permanent residence: town-1, village-2 | |
(write address: region, community)
5. Workplace, speciality _
( for pupils, students- the name of education establishment; for children - the name of child's establishment, school; for invalids -kind and
group of disability
6. Reffered by _____________________
(name of medical establishment) _ hours from the beginning of
7. Hospitalized: urgently - 1, after_
disease, receipt of trauma; in the planned order - 2 | !□
8. Directional diagnosis (before hospitalization) ___
9. Diagnosis on hospitalization
10. Clinical diagnosis _
The date of making the diagnosis:_
11. Clinical diagnosis:
(sign)
a) Main ________________________
6) Complications _
в) accompanying diagnosis_
Examination for
scabies:
о yes о no
pediculosis :
о yes о no
Data _______ Sign __________
142
Family's and first name
Age
Workplace and specialty
Farther:
Diagnosis
143
Appendix 2
___________________________ Temperature chart ____________________
Card NO _______
Room NO Date
Patients full name _____________________________________
144
P
Day in Hospital
BP
1
2
3
4
5
6
7
8
9
10
11
M E M E M E M E M E M E M E M E M E M E M E
140
200
41
120
175
40
100
150
39
90
125
38
80
100
37
70
75
36
60
50
35
Respiratory rate
Weight
Daily fluid
Diurnal diuresis
Defecation
Change of linen
145
A
Index
Addis sediment count, 44
Admission department,
15 Adult louse, 16
Ampule, 67
Aquathermia pad, 54,57
Anthropometry, 33 В
Baby-friendly hospitals,
106 Bag-valve-mask, 104
Bath, 86
Benzidine test, 42
Benzylbenzoate, 17,18
Blood pressure
measurement, 28 ranges,
31 Body surface area, 79
Bubil, 17 С
Calculation of drugs, 12 Care of the
eyes, 90 Care of the nails, 91 Care of
the nose, 91 Case history, 12
Chemical cold pack, 57 Chemical
examination of urine, 45 Chest
circumference, 34 Children's
hospital, 9 structure, 9 functions, 11
Cold application, 56 Compress cold,
57 warm, 55 Cord stump, 92,93 D
Deontology, 7
Disinfection of medica instruments,
82 Drug administration buccal, 33
enteral, 62 oral, 32
parenteral, 62,63 sublingual, 32
topical, 62 Drug dosage calculation, 77
Duties of a nurse on duty, 11 Duties of a
nurse of manipulation room, 61
E
subcutaneous,
71 Itax, 17,18 L
Length of infants, 33 M
Manipulation room, 61
Medical card, 12,15
Medical documentation, 12
Medical ethics, 7 Mustard
plasters, 53 N
Nasal cannula, 99 Nasal С
PAP, 98 Nechiporenko
tests, 44 Needle, 66 Nits,
16 Nix, 17,18
Non-rebreather mask, 102
Nose swab, 48 Nymphs, 16
О
Ear care, 91
Electric heating pad,
54 Enema, 48
administration, 50
complications, 52
types, 49,50
Enterobiasis, 40
Enterobiasis tape test,
41 Eardrops, 94 Eye
drops, 93 F
Fecal occult blood test, 41
Feeding artificial feeding 109
breastfeeding, 106
nasogastric tube feeding, 111
tube feeding, 110 Fever
medical care, 36 types, 19
Flatus tube, 59 G
Gastric lavage, 58 Genital
care, 88 Gregerson test, 42 H
Hair care, 91 Head
circumference, 33 Heat
application, 53 Helmintic
invasion, 41 Hematest, 42
Hospital reception, 15
Hygiene, 90
Iatrogenic diseases, 9 Ice
collar, 57 Icecap, 57
Infusion intravenous, 63,79
Inhaler, 95 pocket inhaler, 96
steam inhaler, 97 Insulin jet
injector, 66 pens, 65 pump,
66 Injections intradermal,
69,70 intramuscular, 73
intravenous, 76
Oxygen bag, 99 Oxygen
therapy, 98 P
Pacifier thermometers, 21 Para
plus, 17
Partial rebreathing mask, 101
Pediculosis, 16 Perineal care, 88
Permethrin, 17 Pinworm, 40
Pinworm test, 41 Pocket mask,
104 Positions for feeding,
107,108 Pulse assessment, 26
ranges, 27
R
Reception ward, 15 Respiration
counting, 25 ranges, 26
S
Safe, 13 Scabies, 17
Simple face mask, 100
Sinapism, 53 Spacer, 97
Sphygmomanometer, 29
Sponge bath, 36
Stadiometer, 35
Sterilization, 82 Stool
collection, 39 Stool for
ova and parasites, 40
Syringe, 63 insulin
syringe, 64 tuberculin
syringe, 66 Systolic
blood pressure, 35 T
Temperature, 22 an ear
temperature, 26 axillary
temperature, 24 forehead
temperature, 27 oral
temperature, 22 pacifier
temperature, 23 rectal
temperature, 23 temporal
artery temperature, 22
Thermometers types, 20
Throat swab, 46,47 U
Umbilical cord care, 92,93
damping, 93 Urinalysis,
42,43 Urine collector, 43
Urine culture, 45 Urine
dipstick, 45 V
Venturi mask, 102 Vial, 68
Vital signs, 18
W
Weight of infants, 33 of
adolescent, 34 Worm, 40 Z
Zimnitskiy test, 45
147