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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. 92 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