Diploma in Critical Care ManagementFirst year

COURSE CODE: AHE042

COURSE NAME: BSS DIPLOMA IN CRITICAL CARE MANAGEMENT

COURSE DURATION: TWO YEARS

SNo Subject Code Subject

I YEAR

1 AHE042-01 COMMUNICATIVE ENGLISH AND COMPUTER FUNDAMENTALS

2 AHE042-02 STUDY OF THE HUMAN BODY, MICROORGANISM & PSYCHIATRIC DISEASE

3 AHE042-03 FUNDAMENTALS OF NURSING

4 AHE042-04 FIRSTAID & EMERGENCY TECHNIQUES

5 AHE042-05 PRACTICAL - I

6 AHE042-06 PRACTICAL - II

7 AHE042-07 PRACTICAL - III

8 AHE042-08 PRACTICAL - IV

II YEAR

9 AHE042-09 CRITICAL CARE MANAGEMENT

10 AHE042-10 TRAUMA CARE MANAGEMENT

11 AHE042-11 CASUALITY MANAGEMENT

12 AHE042-12 PRACTICAL - V

13 AHE042-13 PRACTICAL - VI

14 AHE042-14 PRACTICAL - VII

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PAPER –I General English and computer fundamentals

Computer:

Definitions and short question (1-2 marks)1. Computer, CPU, Monitor, Key board, Mouse, Printer2. Internet, E-mail, Community services3. Facebook, orkut, google4. File5. Folder6. Ctrl functions7. Formulas in excel8. Word art

Short question (5 marks)1. Importance of computer2. Explain window xp desktop3. Explain regarding parts of computer ( Computer, CPU, Monitor, Key board, printer etc)4. How to turn off , restart, standby computer5. Different lay outs of computer6. Aligning the text (center, left,right, justify etc)7. Font 8. How to setup and run slide show in power point presentation9. Explain excel

Descriptive question (10-15 marks)1. Importance of computer and internet2. Explain email 3. My documents/my computer/recycle been4. Shortcut commands in word5. Preparing a table in word6. Explain power point presentation

English:

Definitions and short question (1-2 marks)1. a[.v. mi> f[rvi[, b.v. mi> f[rvi[2. yi[³y aiT)<kl m&ki[3. (vFinviky/p\ÅniY<viky/nkiriRmk viky mi> f[rvi[4. use of can/may/will/shall/should/must5. use of preposition on/at/in/behind/of/to/for/with/by/and/but6. use of or/so/for/yet/if/because/either or/ neither nor7. definitions of singular/pleural/noun/count noun/pronoun/verb

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8. your name and address9. make list of …. (vocabulary )

Short question (5 marks)1. Importance of English in health sector2. Explain indefinite articles a/an3. Explain definite articles the4. Write essay on

- Human Body- MY SELF- MY HOBBY- MY FATHER- MY MOTHER- MY FAMILY- MY NURSING SCHOOL- THE HOSPITAL- THE DOCTOR- A NURSE- GOOD HEALTH- A MORNING WALK- My city/village,- My best friend, - Visit to a blood bank- Picnic- My favourite: teacher- My country: India

Descriptive question (10-15 marks)1. Explain tenses2. Write your biodata and application for job3. List characteristics of good nurse4. Explain importance of English in Nurse life5. Explain various prepositions

Computer basics

ki[À¼y&Tr b[z)kn) ki[e pN b&k m[Lv) t[mi>Y) n)c[ m&jbni m&d`iai[n) t]yir) krv)

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What is a Computer?

What is an Operating System?

What are the Basic Parts of a Desktop Computer?

The Windows XP Desktop

o Start button: one of the most important tools you will use while working with Windows XP. The Start button allows you to open menus and start applications.

o Taskbar: primarily used to switch between open windows and applications. Learn more about using the Taskbar in a later lesson.

o Icons (or graphical pictures): represent applications, files, and other parts of the operating system. By default Windows XP provides you with one desktop icon, the Recycle Bin. Learn more about the Recycle Bin in a later lesson.

Turn Off and Restart the Computer Minimizing, Maximizing, and Restoring Windows What is a File? Some common file name extensions are:

o doc: Word or WordPad documento xls: Excel spreadsheeto htm or html: HTML file (web page) o ppt : PowerPoint presentation

Creating, Renaming, and Deleting Files What is a Folder? All Windows XP folders include the following features:

o Title bar:contains the name of the folder o Menu bar: contains the File, Edit, View, Favorites, Tools, and Help menus. o Navigation bar: contains the Back, Forward, Up, Search, Folders, and Views buttons.o Address bar: shows current folder location. Use the drop down arrow to navigate

your computer's places. o White space: displays contents of the folder (folders and files)o File and Folder Tasks list: a convenient list of tasks o Other Places: convenient list of your computer's places

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o Details: describes the folder

Creating, Renaming, and Deleting Folders What is a Drive? Introduction to My Documents

o My Documents is a folder that provides you with a convenient place to store your important files and folders. Remember, you can quickly reach My Documents in the Start menu or by double-clicking the My Documents icon on your desktop.

o My Computer is another tool you can use to manage files and folders. With this tool, you can create, rename and move folders and copy, print, move, delete and rename files. It also allows you to gain access to other system tools.

Copying Files and Folders What is the Recycle Bin? Opening the Search Companion Change in View

o Normal view is best used for typing, editing, formatting and proofreading. It provides a maximum amount of space without rulers or page numbers cluttering your view.

o Web Layout view shows you what your text will look like on a web page.o Print Layout view shows you what your document will look like when it is printed.

Under Print Layout view you can see all elements of the page. Print Preview shows you this as well.

o Outline view is used to create and edit outlines. Outline view only shows the headings in a document. This view is particularly handy when making notes.

o Full Screen view displays ONLY the document that you are working on. All the other pieces of the Word window are removed except for one button that allows you to Close View Screen.

Saving a New File Save As Dialog Box Backspace and Delete

o Use the backspace and delete keys (on your keyboard) to erase text in your document.

o The backspace key erases the text to the left of the insertion point one character at a time.

o The delete key (located under the Insert key) erases the text to the right of the insertion point.

Using Undo - Ctrl + Z

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Using Repeat - Ctrl + Yo The Repeat feature allows you to repeat the last action and can help to save a lot of

time as you create your document. Cut and Paste: Copy and Paste:

Ctrl+C = copy Ctrl+X = cut Ctrl+V = paste

Using Find - CTRL + F Using Replace - CTRL + H Aligning Text

Click the Align Left, Center, Align Right, or Justify button on the Formatting toolbar.

Using Page Setup to Specify Margins Bold, Italics and Underline

Font NamesUsing Color

Font Size Bullets and Numbering To Create a Bulleted List: To Create a Numbered List: Use of Symbols Working with Tables Row - A row runs horizontal in a table and is divided by borders.

Borders - Separating lines in the table.Column - A column runs perpendicular in a table and is divided by borders.

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Cell - A cell is the box that is created when your rows and your columns intersect each other. The cell contains your data or information.

Creating Tables Using the Insert Table Dialog Box: Inserting and Deleting Columns and Rows To Add Rows to Your Table: To Insert Rows in the Middle of the Table: To Delete Rows: To Delete Single Table Cell: To Adjust Columns, Rows, and Cell Size: Adding Borders Add Shading Introduction to Word Graphics

o AutoShapes: including Lines, Curves, and Textboxeso WordArt drawing objects

WordArt Drawing Objects

Inserting Clip Art Inserting Pictures from your Computer Changing the Appearance of your Pictures

Powerpoint presentation:

Essay on preparing powerpoint presentationHow to design new slide in presentation?How to run presentation.

Micro soft excelPreparing table in excelFormulas in excel… sum, deduction, multiplication

General English

Importance of English in Nursing:Singular and Plural Nouns : a[k vcn an[ bh& vcn

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A noun names a person, place, thing, or idea. : Noun a[Tl[ nimFor the plural form of most nouns, add s.

bottle – bottles cup – cups

For nouns that end in ch, x, s, or s sounds, add es. box – boxes watch – watches

For nouns ending in f or fe, change f to v and add es. wolf – wolves wife – wives

Some nouns have different plural forms. child – children woman – women man – men

Nouns ending in vowels like y or o do not have definite rules. baby – babies toy – toys

A few nouns have the same singular and plural forms. sheep – sheep deer – deer

Indefinite::Articles—a,an

an—used before singular count nouns beginning with a vowel (a, e, i, o, u) or vowel sound:gN) Skiy t[vi nim ni p\Ym axrni[ uµcir Avr hi[y Ryir[

an apple, an elephant, an issue, an orangea—used before singular count nouns beginning with consonants (other than a, e, i, o, u):gN) Skiy t[vi nim ni p\Ym axrni[ uµcir Äy>jn hi[y Ryir[

a stamp, an honest an M.B.A. a B.B.A.

2. Definite Article (the)Used to indicate a noun that is definite or has been previously specified in the context:ci[kks p\kirn& nim aYvi agiuni vikymi> vpriy[l hi[y t[ nim b)ji vikymi> vprit& hi[y t[ni miT[

Please close the door. I like the clothes you gave me.

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Used to indicate a noun that is unique: anºy hi[y t[v& nim

Praise the Lord! The Narmada River is near to Bharuch.

Unit : 3 Capitalization

Capitalization means using a capital letter (for example, A instead of a). Always capitalize the following:

The first word in a sentence. vikyni[ p\Ym axr I grew up in India. S he left a message on my phone.

The pronoun I. “I” = h&> Yt& hi[y Ryir[ This country is where I dreamed of.

The first letter of a proper noun (specific name). nim , aTkni[ p\Ym axr D avid wants to play soccer with us.

The first letter of months, days, and holidays (but not seasons). Mh)ni, (dvsi[ an[ rjiai[ni[ p\Ym axr, ät&ai[ nh).

Today is June 8, 2011. Sushil’s birthday is this Thursday.

The first letter of nationalities, religions, races of people, and languages. riOT^)yti, Fm<, ji(t, BiPini p\Ym axr

We often eat Italian food.The first letter in a person’s title.

This is Dr. Simon. I got it from Mr. Tom.

Geographic areas: cities, states, countries, mountains, oceans, rivers, etc. Sh[r, rijy, d[S, pv<ti[, sm&Wi[, nd)ai[ vg[r[

My destination is Mumbai, India.The first letter of each major word in the title of a book, movie, article, etc. p&Atkni (SP<k an[ ai p\kirni lKiNni dr[k S¾di[ni[ p\Ym axr

Lord Krishna’s Shrimad Bhagvad Gitais my favorite novel.

Count nouns gN) Skiy

pen, computer, bottle, spoon, desk, cup, television, chair, shoe, finger, flower, camera, stick, balloon, book, table, comb, etc.

Non-count nouns gN) n Skiy

water, wood, ice, air, oxygen, English, Spanish, traffic, furniture, milk, wine, sugar, rice, meat, Possessive Nouns mil)k) dS<k

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a[.v. John's book Kerry's car Grandma's mirror

b.v. The kids' toys My parents' house The teachers' lounge

A pronoun takes the place of a noun. : nimn) j³yia[ vipr) SkiyPersonal Pronouns Äy(ktdS<k

I go to school. You are a student.

The word ‘it' refers to an object {vAt& aYvi Äy(kt}: I drank it. It is big.

Memorize the personal pronouns:

Singular Subject

Singular Object

Singular Reflexive

Plural Subject

Plural Object

Plural Reflexive

First I me myself we us ourselves

Second you you yourself you you yourselves

Third Male he him himself they them themselves

Third Female she her herself they them themselves

Third Neutral it it itself they them themselves

Be (k\yipd a(AtRv dSi<v[ C[. t[n) siY[ subject = (vPy ji[Diy[l hi[vi[ ji[ea[.

I am a doctor. ah)> “am” be C[ jyir[ “doctor” subject C[. He is sleepy.

Negative sentences need ‘not' after the verb. nkiriRmk viky I am not a doctor. He is not sleepy.

The verb comes first in interrogative sentences. p\ÅniY< viky Am I a doctor?

"Are not" (is not) can be shortened to "aren't" (isn't).

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He isn't sleepy. We aren't there.

Present Negative Interrogative

I am I am not Am I?

You are You are not (aren't) Are you?

He is He is not (isn't) Is he?

She is She is not (isn't) Is she?

It was It was not (wasn't) Was it?

We are We are not (aren't) Are we?

You are You are not (aren't) Are you?

They were They were not (weren't) Were they?

Action VerbsAction verbs express action and are the most common verbs. t[ kimg)r) dSi<v[ C[ an[ Äyipk p\miNmi> vpriy C[.Action verbs need s at the end with third-person, singular subject. a[.v. vikymi> (k\yipdn) piCL s lgivi[

He eats bread. She walks to the station.

Negative sentences need do not, does not, or did not. I do not eat bread. It does not float on the sea.

Interrogative sentences begin with do, does, or did. Do you eat bread? Does he eat bread?

Affirmative Sentence

Negative Sentence Interrogative Sentence

I sing a song. I do not (don't) sing a song. Do I sing a song?

You sing a song. You do not (don't) sing a song. Do you sing a song?

He (she) sings a song.

He (she) does not (doesn't) sing a song.

Does he (she) sing a song?

We sing a song. We do not (don't) sing a song. Do we sing a song?

They sang a song. They did not (didn't) sing a song.

Did they sing a song?

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Unit 8 Tense kiL

Verb tense tells you when the action happens. There are three main verb tenses: present, past, and future. Each main tense is divided into simple, progressive, perfect, and perfect progressive tenses.

(k\yi kyir[ bn) t[ verb tense Y) jiN) Skiy C[. m&²y kiL #iN p\kirni C[. vt<min kiL, B&tkiL an[ B(vOy kiL, dr[k m&²y kiL fr) sidi[, cil&, p*N< an[ cil& p*N< a[m cir Bigmi> vh[>ciy[li hi[y C[. n)c[ dr[k kiL miT[n) viky rcni aip[l) C[.

Simple Progressive

Present finish am/is/are finishing

Past finished was/were finishing

Future will finish

will be finishing

Simple Tense sidi[ kiL

kiym) aYvi (nym)t bnt) GTni miT[ sidi[ kiL vpriy. sidi vt<minkiLmi> be ni $p tr)k[ do vpriy C[ j[ni[ simiºy vikyp\yi[gmi> li[p Yiy C[ {#i).p&.a[.v. mi> does vpriy C[ j[ni[ li[p Ye (k\yipd piCL s lgivvimi> aiv[ C[.}

run I run a marathon this year. (present) I ran a marathon last year. (past) I will run a marathon next year. (future)

eat You eat lunch now. You ate lunch an hour ago. You will eat lunch in one hour.

see They see a movie once a week. They saw a movie yesterday. They will see a movie tomorrow.

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Progressive Tensej[ t[ vKt[ (k\yi cil& C[ t[v& dSi<vvi progressive tense vpriy C[ j[mi> be ni $p tr)k[ am/is/are/was/were/will be/shall be + (k\.p.n& ing viL& $p vpriy C[.run

I am running a marathon right now. (present progressive) I was running a marathon at this time last year. (past progressive) I will be running a marathon next Sunday. (future progressive)

eat You are eating lunch now. You were eating lunch when you saw me. You will be eating lunch in the meeting.

Unit 10 Auxiliary Verbs shiyk (k\yipd

An auxiliary verb n& kiy< main (full) verb n[ mdd krvin& C[ t[Y) t[n[ "helping verb." pN kh[ C[.

Can : Skv& - xmti

Used to express ability (to be able to do something): xmti dSi<v[

I can make jewelry. He can’t speak French. Can you open this jar?

May : Skyti

Used to ask for formal permission: ai]pcir)k s>m(t m[Lvvi

May I come in? May I say something now? May I ask one question?

Will : hS[

Used to express desire, preference, choice, or consent: eµCi, ps>dg) aYvi s>m(t dSi<vvi

I will take this duty. Will you stop talking like that?

Used to express the future: B(vOy dSi<vvi

It will rain tomorrow. The news will spread soon.

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Shall : hS[

Mainly used in American English to ask questions politely (it has more usages in British English). For the future tense, will is more frequently used in American English than shall.American English mi> t[ni[ vFir[ upyi[g Yti[ nY) pr>t& mZdZtip*v<k p\Ån p&Cvimi> vpriy C[.

Shall we dance? Shall I go now? Let’s drink, shall we?

Should : krv& ji[ea[ : frj

Often used in auxiliary functions to express an opinion, suggestion, preference, or idea: mt, s*cn,ps>dg) aYvi (vcir dSi<vvi

You should rest at home today. I should take a bus this time. He should be more thoughtful in the decision-making process.

Must : krv& j ji[ea[ - aig\h

Used to express something formally required or necessary: ai]pcir)k r)t[ j$r) bibt dSi<vvi- aig\hni aY<mi>

I must complete the project by this week. The government must provide health care for everybody.

Have to /Has to : krv& j pDS[ - frj piDvimi> aiv[ Ryir[

Used to express something compulsary required or necessary: frJyit r)t[ j$r) bibt dSi<vvi- aig\hni aY<mi>

I have to complete the project by this week. The government has to take care of health of everybody.

Unit 11 Prepositions nimyi[g) aÄyy

"On", "At", and "In"A preposition is a word that links a noun, pronoun, or noun phrase to some other part of the sentence. nim, sv<nim aYvi S¾dsm&h nimn[ aºy viky siY[ ji[Dti S¾dn[ preposition kh[ C[.

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Preposition nkk) krvi miT[ ki[e Kis (nym hi[tin Y) , vi>c)n[ aYn[ si>BL)n[ mi[Ti Big[ a¿yis Ye jiy C[.

to the office ai[f)s pr at the desk m[j pr on the table T[bl pr in an hour a[k klikmi> about myself miri (vP[

A preposition is used to show direction, location, or time, or to introduce an object. (dSi, AYin, smy aYvi ki[e vAt&ni p(rcy miT[ preposition vpriy C[.

On uprUsed to express a surface of something: ki[e vAt&n) spiT) dSi<vvi

I put an egg on the kitchen table.Used to specify days and dates: (dvs an[ ti(rK dSi<vvi

The garbage truck comes on Wednesdays.Used to indicate a device or machine, such as a phone or computer: vAt& aYvi m(Sn dSi<vvi

He is on the phone right now.Used to indicate a part of the body: S(rrni Big dSi<vvi

The stick hit me on my shoulder.

At : pr

Used to point out specific time: ci[kks smy dSi<vvi

I will meet you at 12 p.m.Used to indicate a place: ki[e AYL dSi<vvi

There is a party at the club house.

In : mi>, a>dr

Used for unspecific times during a day, month, season, year: (dvs, m(hni[, ät& aYvi vP<mi> aci[kks smy dSi<vvi

She always reads newspapers in the morning.Used to indicate a location or place: AYin aYvi AYL dSi<vvi

She looked me directly in the eyes.

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Behind : n) piCL, Beside : n) bij&mi, Below : n) n)c[, Above : n) upr, Near : n) nJk, Opposite : n) sim[

Used to indicate a location or place: AYin aYvi AYL dSi<vvi

I am currently staying in Maa Kaamal Hostel My hostel is behind my school. My school is located beside Police station, Mahidharpura Police station is near Bhagal. My hostel is opposite to temple. My room is on first floor above room no 5 and below room no 16 of second floor.

Of : n&>

Used for belonging to, relating to, or connected with: sb>F dSi<vvi

The secret of this game is that you can’t ever win. The highlight of the show is at the end.

Used to indicate reference: s>dB< dSi<vvi

I got married in the summer of 2000. This is a picture of my family.

Used to indicate an amount or number: j¸Yi[ aYvi s>²yi dSi<vvi

I drank three cups of milk. A large number of people gathered to protest.

To : n[

Used to indicate the place, person, or thing that someone or something moves toward, or the direction of something: n) trf gt) dSi<vvi

I am heading to the entrance of the building. The package was mailed to Mr. Kim yesterday.

Used to indicate relationship: sb>F dSi<vvi

This letter is very important to your admission. My answer to your question is in this envelop.

Used to indicate a time or a period: smy aYvi smygiLi[ dSi<vvi

I work nine to six, Monday to Friday. It is now 10 to five. (In other words, it is 4:50.)

For : miT[

Used to indicate the use of something: ki[e vAt&ni vpriS dSi<vvi

This place is for exhibitions and shows.

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I baked a cake for your birthday.Used to mean because of: kirN dSi<vvi

I am so happy for you.Used to indicate time or duration: smy aYvi smygiLi[ dSi<vvi

He’s been famous for many decades.

With : siY[

Used to indicate being together or being involved: siY aYvi ji[DiN dSi<vvi

I ordered a sandwich with a drink. He was with his friend when he saw me.

Used to indicate feeling: ligN) dSi<vvi

I am emailing you with my sincere apology. He came to the front stage with confidence.

Used to indicate agreement or understanding: s>m(t aYvi smj*t) dSi<vvi

Are you with me? She agrees with me.

By : ni oiri

Used to indicate proximity: Can I sit by you?

Used to indicate a mean or method: mi¹ym aYvi p¹F(t dSi<vvi

Please send this package to Russia by airmail. I came here by subway.

Unit 12 Coordinating Conjunctions and Correlative ConjunctionsA conjunction joins words or groups of words in a sentence. vikymi> b[ aYvi b[ krti vFir[ S¾di[n[ ji[Dvin& kiy< conjunction n& C[.

1. Coordinating Conjunctions Connect words, phrases, or clauses that are independent or equal Avt>#i aYvi srKi S¾di[, vikyi[ aYvi vikyi>S n[ ji[D[ C[.

and, but, or, so, for, yet, and not

2. Correlative Conjunctions Used in pairs ji[D)mi> vpriy C[.

both/and, either/or, neither/nor, not only/but also

3. Subordinating Conjunctions

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Used at the beginning of subordinate clauses vikyn) S$aitmi> m&kiy although, after, before, because, how, if, once, since, so that, until, unless, when, while, where, whether, etc.Coordinating Conjunctions1. And—means "in addition to": an[

We are going to a zoo and an aquarium on a same day.2. But—connects two different things that are not in agreement: pr>t&

I am a night owl, but she is an early bird.3. Or—indicates a choice between two things: aYvi

Do you want a red one or a blue one?4. So—illustrates a result of the first thing: t[Y), agiuni vikyni an&s>Finn[ aigL vFirvi

This song has been very popular, so I downloaded it.5. For—means "because": n[ kirN[

I want to go there again, for it was a wonderful trip.6. Yet—indicates contrast with something: ti[ pN

He performed very well, yet he didn’t make the final cut.Correlative Conjunctions1. Either/or a[k aYvi b)j&

I am fine with either Monday or Wednesday. You can have either apples or pears.

2. Neither/nor ph[l& pN nh) an[ b)j& pN nh)

He enjoys neither drinking nor gambling. Neither you nor I will get off early today.

3. Not only/but also ph[l& ti[ Kr& j pr>t& b)j& pN

Not only red but also green looks good on you. She got the perfect score in not only English but also math.

Subordinating Conjunctions1. Although—means "in spite of the fact that": Cti pN

Although it was raining, I ran home.2. After—indicates "subsequently to the time when": bid

Please text me after you arrive at the shopping mall.3. Before—indicates "earlier than the time that": ph[li

He had written a living will before he died.4. Because—means "for the reason that": kirN k[

Because he was smart and worked hard, he was able to make a lot of money. They stopped building the house because it was pouring.

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5. If—means "in the event that": ji[ hi[y/Yiy ti[

If it is sunny tomorrow, we can go to the beach.6. Since—means "from the time when": ci[kks smy Y)

I’ve been a singer since I was young.9. When—means "at that time": t[ smy[

When I came in the room, everyone looked at me.

Unit 13 “Wh” questionsWh questions ni[ upyi[g (v(vF AYL, (AY)t), Äy(kt, vAt&, smy an[ kirN jiNvi miT[ Yiy C[.

WH- word + “do” + SUBJECT + VERB PHRASE

Who: ki[N Who is known as God of Cricket?Sachin Tendulkar is known as God of Cricket.

Who is your Father?My father is a farmer.

Who killed Mahatma Gandhi?Nathuram Godse Killed Mahatma Gandhi.

Whose: ki[n&Whose book is this ?This is Ramesh’s book.

Whose performance is best in class?Asha’s performance is best in class.

What: S&>? What hit the dog?A car hit the dog

What if Radha’s favourite subject?English is Radha’s favourite subject.

What is your name?My name is Akash Patil.

What did Nita buy?

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Nita bought umbrella.

When: kyir[?When was Vijay’s appointment?Vijay’s appointment was at four o’clock.

When did Nitin arrive?Nitin arrived afternoon.

When is Diwali?Diwali is in the month of October.

Which: ky&?Which book do you like most?I like Shrimad Bhagvad Gita most.

Which window is broken?The second window is broken.

Which car met accident?GJ 5-2250 met accident.

Where: kyi>Where do you live?I live in Surat.

Where did Gandhiji born?Gandhiji born in Porbandar.

Where are the keys?The keys are on the table.

Why: Si miT[?Why is Mitul thin?Mitul is thin because he is sick.

Why do you worry?I am worried for my exams.

Why did Sita kidnapped? Sita kidnapped as she crossed Laxman Rekha

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How : ke r)t[?How beautiful is Priya?Priya is very beautiful.

How did Rakesh run to school?Rakesh ran quickly to school.

How was your day today?It was very fine.

Unit 14 Conversation vitc)t

Greeting a(Bvidn

Hi, hello. Good morning, good afternoon, good evening. How are you? How are you doing? How do you do?

Introducing yourself: pi[tini[ p(rcy aipvi[

Introducing others: aºyni[ p(rcy aipvi[

Unit 15 Vocabulary S¾dB>Di[L

PeopleMan, woman, baby, boy, girl, child, old man,

Gender: (l>g

a>g\[J g\imrmi> pN g&jrit)n) j[mj #iN l)>g aiv[l) hi[y C[.

p&Ãl)>g – p&$Pvick : Masculine

A#i)l)>g- A#i) vick : Feminine

niºytr ji(t: Neuter

Man, father, uncle, boy, husband

Woman, mother, aunt, girl, wife

child, cousin, teacher, relation, parents

Family members

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Daughter, son, father, mother, brother, husband, wife, children, parents, grand parents, grand father, grand mother, uncle, aunty, neighbour, cousin, nephew, in laws (brother in –law, son in-law)

Cardinal Numbers: Zero, one, two...., ten, twenty, thirty,..., hundred, thousand, lac,...,

Ordinal Numbers - used for ranking:1st: first, second, third, fourth, fifth, sixth, seventh, eighth, ninth, tenth, eleventh, twelfth, twenty second, twenty third, fiftieth, hundredth, etc...

Months days and times of the day January, February,...., Monday, Tuesday...., Morning, Early morning, noon, afternoon, evening, night, Midnight

Seasons Summer, Winter, Monsoon, autumn, spring

Weather:What is the weather like?It is rainy.Rainy, cloudy, windy, snowy, sunny, nice, fine, cold, warm, hot etc

Occupations (jobs) Carpenter, cook, farmer, fireman, fisherman, gardener, doctor, engineer, teacher, advocate, lawyer, journalist, nurse, laboratory assistant, surgeon, physician, plumber, mechanic, painter, postman, policeman, secretary, singer, taxi driver, soldier, waiter, pilot, tailor, actor, goldsmith etc..

ColoursBlack, white, blue, green, yellow, pink, brown, grey, orange, purple, red etc

Parts of the bodyArm, back, beard, ear, elbow, eye, eyebrow, eyelashes, face, finger, foot, hair, hand, leg, mouth, neck, nose, shoulder, tongue, tooth, lips, moustache, knee, head etc..

Rooms and Places in the Home Bedroom, Living room ,Bathroom, Hall, Shed, Basement, Porch, Terrace, Study room, Balcony etc.

Objects of the homeTelevision, remote control, power point, plug, arm chair, chair, table, dining table, door, door handle, ward rob, bedside table, bed, carpet, mirror, curtain, drawer, towel, vase etc

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AnimalsLion, cheetah, tiger, fox, buffalo, cow, goat, dog, cat, monkey, donkey etc

BirdsParrot, sparrow, peacock, dove, cuckoo, hen Flowers Rose, lily, sunflower, lotus etc

Electrical - Electronic appliancesFridge, television, radio, iron, fan, air conditioner, oven, air cooler etc

Cities, Villages, States, Countries, Male names, Female names, Surnames Complete this list

Write essay on - Human Body- MY SELF- MY HOBBY- MY FATHER- MY MOTHER- MY FAMILY- MY NURSING SCHOOL- THE HOSPITAL- THE DOCTOR- A NURSE- GOOD HEALTH- A MORNING WALK- My city/village,- My best friend, - Visit to a blood bank- Picnic- My favourite: teacher- My country: India

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BHARAT SEVAK SAMAJNATIONAL DEVELOPMENT AGENCY, PROMOTED BY GOVERNMENT OF INDIA

CENTRAL BOARD OF EXAMINATIONSBSS NATIONAL VOCATIONAL EDUCATION MISSION

Paper-ICOMMUNICATIVE ENGLISH AND COMUTER FUNDAMENTALS (MS-OFFICE)

_______________________________________________________________________________TIME : 3 HOURS

MARKS: 100INSTRUCTIONS:-

Write answer to each question in proportion to the marks allotted During the first 15 minutes read the questions carefully

_______________________________________________________________________________I. Fill in the blanks: 10 x 1 = 10

1. The police booked ________ F.I.R. (a , an, the )2. It is ______ operation theatre (a, an, the )3. Put _________ sugar in this cup. (have , some, many)4. ________ Taj Mahal is in Agra (a , an, the )5. I ________ not found any inquiries useful. (have to, has, have)6. ____________ provides the facility to find and replace specific in worksheet7. www stands for __________________________________8. ___________________is used to create charts and graphs9. ______________ is the shortcut command of “select all” 10. ______________ is the shortcut command of copy the selected portion

II. Write short notes on following 10 x 2 = 201. CPU2. Software3. Noun4. Verb5. Discipline6. Biodata

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7. Phrase8. Article A and An9. My computer10. Face book

III. Write brief answers for 5 questions 5 x 5 = 25

1. Why English is known as link language? 2. Explain article “the” 3. Write about internet explorer 4. Explain kinds of computers 5. Explain importance of hardware and software 6. What is the importance of page setup?7. Explain copying cutting and renaming files 8. Prepare your detailed biodata

IV. Write long answers for 3 questions 15x 3 = 45

1. What is the importance of preparing presentation in power point? Explain some important commands to prepare powerpoint presentation

2. Explain simple and continuous present tense with examples. 3. Explain “WH” questions4. Write an essay on (nb>F lKi[

A hospital and medical – paramedical staff hi[(ApTl an[ m[(Dkl, p[rim[(Dkl ATif5. Explain what is the importance of internet? eºTrn[Tn& mhRv smjivi[6. Describe use of computer in now a days world. aiF&n)k jgtmi> ki[À¼y&Trni upyi[g

smjivi[

mi> kiml si]n& kÃyiN kr[

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PAPER*2 STUDY OF THE HUMAN BODY, MICROORGANISM & PSYCHIATRIC DISEASE

HUMAN BODY: GUJARATI BOOK OF ANATOMY AND PHYSIOLOGYMICRO ORGANISM: NOTES OF MICRO BIOLOGYPHYSCHIATRIC DISEASE: NOTES OF PSHYCHIATRIC DISEASE

Question bank

Anatomy and physiology:

Definitions

Anatomy Virus Living matterPhysiology Bacteria CellSociology Communicable disease TissuePsychology WHO OrganPathology cytoplasm SystemMitochondria Synovial membrane OrganelleGolgi apparatus anterior Muscular tissueSerous membrane inferior Posteriorsuperior Thorasic cavity Dorsal cavity

Unit-2 the skeletal system

bone Skeletal system SkeletonLong bone cartilage Bone marrowFrontal bone Short bone Flat boneTemporal bone Zygomatic bone JointVertebral column vertebrae Cranial bonesL1-L5 fibula Maxillaradius scapula T1-t12Pelvic girdle Shoulder girdle clavicle

Unit-3 the muscular system

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Elasticity of muscle Muscular system Short musclesSkeletal muscle Visceral muscle Voluntary muscleSmooth muscle Cardiac muscle DeltoidInvoluntary muscle Trapezius muscle Gluteus maximus

Unit: 4 circulatory system

CVS Circulatory system Capillaryartery plasma Erythrocytesblood Thrombocytes HaemoglobinLeukocytes Blood clotting Normal RBC countNormal WBC count Pulmonary artery Normal hb countPulmonary valve Pulmonary circulation Mitral valveTricuspid valve Blood pressure Coronary circulationSystemic circulation Rh factor AntibodyCardiac cycle Fetal circulation ECG

Unit 5 digestive system

GI system metabolism Dietteeth emylaze Salivary glandEnzyme Cardiac sphincter Pyloric sphincterGastric juice Peristalsis Peptic acidDuodenum Bile juice IleumLiver Insulin Ascending colonPancreatic juice Appendix Sigmoid colonRectum Gall bladder Descending colon

Unit 6 respiratory system

larynx Respiratory system InspirationBronchial tree Expiration BronchiPrimary bronchi Nasal cavity Alveolicarina Trachea pleuraMedulla oblongata Bronchiole diaphragm

Unit-7 urinary system

Urinary system urination Micturationkidney ureter UrethraUrinary bladder nephron Renal artery

Unit-8 nervous system

Axon Neuron PNS

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Spinal cord CNS CerebrumMedulla oblongata brain Pituitary epidermis forebrain Sweat glandTaste bud cerebellum IrisTympanic membrane hypothalamus Olfactory bulbretina Cornea Middle ear

Unit-10

Endocrine system

Endocrine system Master gland HormonePituitary gland ovary Hypothalamus thyroxin Prostate gland Thyroid glandParathyroid hormone adrenocotricotropine TSHGonalds Thymus gland Pineal gland

Micro biology:

Microbiology Micro organism Living matterNon living matter pathogen Non pathogenicInfectious disease Communicable disease VirusBacteria fungus ParasiteMicro scopic Macroscopic TuberculosisAIDS Non communicable ExteromophilesMicrobes WHO MalariaInfluenza Cholarae Typhoid

Psychiatric diesease

Anxiety Eating disorders NarcolepsyMood disorders Impulse controlled disorders AnxietyManic depression Paraphilias disorders Mood disordersAdjustment disorders Insomnia Manic depressionDiassociative disorders Hypersomnia Adjustment disordersMultiple personality disorder pshychitrist PsychologyMental disorders phobia Mania

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Short and detailed questions

Unit-11. Draw cell2. How body forms from cell3. Characteristics of living matter4. Classification of tissue5. Classification of membrane6. Body cavities7. Systems of body

Unit-2

8. Functions of skeletal system9. Classification of bones10. Rib cage11. Vertebral column12. Upper limb13. Lower limb

Unit-314. Functions of muscular system15. Classification of muscular system

Unit-416. Functions of blood17. Composition of blood18. Blood cells19. Explain RBC20. Explain WBC21. Explain platelets22. Explain haemoglobin23. Structure of heart24. Circulation of blood through heart25. Coronary circulation26. Pulmonary circulation27. Systemic circulation28. Comparison of arteries and vein29. Heart valve diagram

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30. Importance of blood group

Unit-531. Draw digestive tract32. Draw small intestine33. Draw large intestine34. Functions of digestive system35. List juices secreted during digestion36. Functions of small intestine37. Functions of large intestine38. Functions of liver39. Importance of gall bladder40. Importance of pancreas

Unit-641. Respiratory process42. Draw respiratory system43. Importance of nose and nasal cavity44. Pharynx45. Larynx46. Structure of lungs47. Lobes of lungs48. Bronchial tree49. Importance of alveoli

Unit-750. Urinary process51. Structure of kidney52. Functions of kidney53. Draw urinary tract

Unit-854. Draw neuron55. Classification of nervous system56. Draw brain anatomy57. Functions of brain58. Draw skin59. Draw eye anatomy

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Unit-1060. List endocrine glands61. Explain pituitary gland62. Thyroid gland63. Gonalds64. Pancreas65. Thymus gland66. Prostate gland

Micro biology:

1. Explain microbiology2. Draw and explain microscope3. Explain regarding 1. Virus 2. Bacteria 3. Parasite 4. Fungus4. Routes of infection spreading5. Explain some water born infections6. Explain some air born infections7. Explain various isolation techniques8. Write notes on

AIDS Typhoid Tuberculosis Malaria Influenza

Psychiatric disease:

1. Explain classification of psychiatric disease2. Write notes on etiology, diagnosis, treatment and prognosis of following

Anxiety Mood disorders Manic depression Adjustment disorders Dissociative disorders Multiple personality disorder Eating disorders Impulse controlled disorders Paraphilias disorders Insomnia Hypersomnia Narcolepsy

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Schizophrenia

Microorganism

A microorganism (also spelled as microrganism) or microbe is an organism that is microscopic (too small to be seen by the human eye).

The study of microorganisms is called microbiology.

Microorganisms include bacteria, fungi, archaea or protists, but not viruses and prions, which are generally classified as non-living.

Most microorganisms are single-celled, or unicellular, but some are microscopic, and some unicellular protists are visible to the average human. Microorganisms live almost everywhere on Earth where there is liquid water, including hot springs, on the ocean floor, and deep inside rocks within Earth's crust.

Microorganisms are critical to nutrient recycling in ecosystems as they act as decomposers.

As some microorganisms can also fix nitrogen, they are an important part of the nitrogen cycle.

However, pathogenic microbes can invade other organisms and cause diseases that kill millions of people every year. Microorganisms can be found almost anywhere in the taxonomic organization of life on the planet.

Bacteria and archaea are almost always microscopic, while a number of eukaryotes are also microscopic, including most protists and a number of fungi.

Viruses are generally regarded as not living and therefore are not microbes, although the field of microbiology also encompasses the study of viruses. Habitats and ecology Microorganisms are found in almost every habitat present in nature.

Even in hostile environments such as the poles, deserts, geysers, rocks, and the deep sea, some types of microorganisms have adapted to the extreme conditions and sustained colonies; these organisms are known as extremophiles.

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Extremophiles have been isolated from rocks as much as 7 kilometres below the earth's surface, and it has been suggested that the amount of living organisms below the earth's surface may be comparable with the amount of life on or above the surface.

Extremophiles have been known to survive for a prolonged time in a vacuum, and can be highly resistant to radiation, which may even allow them to survive in space.

Many types of microorganisms have intimate symbiotic relationships with other larger organisms; some of which are mutually beneficial (mutualism), while others can be damaging to the host organism (parasitism).

If microorganisms can cause disease in a host they are known as pathogens. Microorganisms are vital to humans and the environment, as they participate in the Earth's element cycles such as the carbon cycle and nitrogen cycle, as well as fulfilling other vital roles in virtually all ecosystems, such as recycling other organisms' dead remains and waste products through decomposition.

Microbes also have an important place in most higher-order multicellular organisms as symbionts. Microorganisms are the cause of many infectious diseases.

The organisms involved include bacteria, causing diseases such as plague, tuberculosis and anthrax; protozoa, causing diseases such as malaria, sleeping sickness and toxoplasmosis; and also fungi causing diseases such as ringworm, candidiasis or histoplasmosis.

However, other diseases such as influenza, yellow fever or AIDS are caused by viruses, which are not living organisms and are not therefore microorganisms.

As of 2007, no clear examples of archaean pathogens are known, although a relationship has been proposed between the presence of some methanogens and human periodontal disease.

Viruses

With the exception of newly discovered prions, viruses are the smallest agents of infectious disease. Most viruses are exceedingly small (about 20 - 200 nanometers in diameter) and effectively round in shape. They consist of little more than a small piece of genetic material surrounded by a thin protein coating. Some viruses are also surrounded by a thin, fatty envelope.

Viruses are different from all other infectious microorganisms because they are the only group of microorganisms that cannot replicate outside of a host cell. Because viruses do not eat food, but instead seize materials and energy from host cells by hijacking cellular machinery, some scientists argue that they are more like complex molecules than living creatures. Viruses are known to infect nearly every type of organism on Earth. Some viruses, called bacteriophages, even infect bacteria.

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At Antimicrobial Test Labs, we have made use of the physical similarity between animal viruses and certain bacteriophages to do faster, more cost-effective antiviral testing. Simply put, certain bacteriophages are great surrogates for mammalian viruses when it comes to disinfectant testing.

Bacteria

Bacteria are ten to 100 times larger than viruses. Typically, they are typically 1 to 3 microns in length and take the shape of a sphere or rod. Most bacteria consist of a ring of DNA surrounded by cellular machinery, contained within a fatty membrane.

They acquire energy from the same essential sources as humans, including sugars, proteins, and fats. Some bacteria live and multiply in the environment while others are adapted to life within human hosts. Some bacteria can double in number every fifteen minutes while others may take weeks or months to divide and grow.

Bacteria cause many types of diseases, ranging in severity from mild skin irritation to lethal pneumonia.

Parasites

Parasites are part of a large group of organisms called eukaryotes. Parasites are different from bacteria or viruses because their cells share many features with human cells including a defined nucleus.

Parasites are usually larger than bacteria, although some environmentally resistant forms are nearly as small. Some parasites only replicate within a host organism, but many can multiply freely in the environment. Parasites can be made of one cell, as is the case with Giardia, or many cells, as is the case with parasitic worms.

In developing countries, parasitic worms are a major source of disease. Waterborne, non-worm parasites, including Giardia and Cryptosporidium are most common sources of parasitic disease in the United States.

Fungi

Fungi are diverse in terms of their shape, size and means of infecting humans. Fungi are eukaryotes, meaning that like parasites, their cells have a true nucleus and complex internal structures.

They are most commonly found as environmentally resistant spores and molds, but can cause disease in humans in the form of yeasts. Fungi most often cause skin infections and pneumonia. Fungal diseases are particularly dangerous to immunocompromised people, such as those suffering from AIDS.

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Psychiatric DisordersThere are over 300 different psychiatric disorders listed in the DSM-IV. With continued research, more are named every year and some disorders are removed or re-categorized. AllPsych includes in these pages the etiology (how it develops), symptoms, treatment options, and prognosis for over 60 adult psychiatric disorders and 8 personality disorders, as well as the names and DSM Codes for over 150 disorders.

Categorizing Mental IllnessPsychiatric Diagnoses are categorized by the Diagnostic and Statistical Manual of Mental Disorders, 4th. Edition. Better known as the DSM-IV , the manual is published by the American Psychiatric Association and covers all mental health disorders for both children and adults. It also lists known causes of these disorders, statistics in terms of gender, age at onset, and prognosis as well as some research concerning the optimal treatment approaches. Mental Health Professionals use this manual when working with patients in order to better understand their illness and potential treatment and to help 3rd party payers (e.g., insurance) understand the needs of the patient. The book is typically considered the ‘bible’ for any professional who makes psychiatric diagnoses in the United States and many other countries. Much of the diagnostic information on these pages is gathered from the DSM IV.

DiagnosingThere is a good deal of overlap among the different diagnoses listed in the DSM IV, which you may notice by browsing these pages. The reason for this is the same as for the overlap in medical diagnoses...rarely is a symptom exclusive of anything, and rarely can a diagnosis be made without a pattern or cluster of symptoms. For example, Depression includes feelings of sadness, but anxiety can lead to sadness, as can phobias, psychosis, and many other disorders. Keep this in mind when reading about specific diagnoses or you may find yourself saying way too frequently "Oh my Gosh, I have that." Diagnoses can only be made by a clinician (e.g., psychologist or psychiatrist) who specializes in these areas and who understands the symptom patterns and idiosyncrasies of each disorder. Don’t self diagnose. If you feel you may have symptoms which are negatively affecting your life, please seek the advice and assistance of a professional. Categories and DisordersMental Disorders are categorized according to their predominant features. For example, phobias, social anxiety, and post-traumatic stress disorder all include anxiety as a main feature of the disorder. All of these disorders are therefore categorized under Anxiety Disorders. The list on the left includes a link to the adult categories which will then link you to specific disorders in that category. For a complete listing of all disorders covered, use the Alphabetical Index. There's a lot of information here so please keep in mind that reading this information does not make you an expert in the nuances of mental health. These pages are provided to increase your knowledge and help guide you to a better understanding of psychopathology.

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Anxiety Disorders Common CharacteristicsAnxiety Disorders categorize a large number of disorders where the primary feature is abnormal or inappropriate anxiety. Everybody has experienced anxiety. Think about the last time a loud noise frightened you and remember the feelings inside your body. Chances are you experienced an increased heart rate, tensed muscles, and perhaps an acute sense of focus as you tried to determine the source of the noise. These are all symptoms of anxiety. They are also part of a normal process in our bodies called the 'flight or flight' phenomenon. This means that your body is preparing itself to either fight or protect itself or to flee a dangerous situation. These symptoms become a problem when they occur without any recognizable stimulus or when the stimulus does not warrant such a reaction. In other words, inappropriate anxiety is when a person's heart races, breathing increases, and muscles tense without any reason for them to do so. Once a medical cause is ruled out, an anxiety disorder may be the culprit.

Mood Disorders Common CharacteristicsThe disorders in this category include those where the primary symptom is a disturbance in mood. In other words, inappropriate, exaggerated, or limited range of feelings. Everybody gets down sometimes, and everybody experiences a sense of excitement and emotional pleasure. To be diagnosed with a mood disorder, your feelings must be to the extreme. In other words, crying, and/or feeling depressed, suicidal frequently. Or, the opposite extreme, having excessive energy where sleep is not needed for days at a time and during this time the decision making process in significantly hindered.

Bipolar Disorder (Manic-Depression) CategoryMood Disorders EtiologyResearch has shown a strong biological component for this disorder, with environmental factors playing a role in the exacerbation of symptoms. SymptomsBipolar Disorder has been broken down into two types:

Bipolar I: For a diagnosis of Bipolar I disorder, a person must have at least one manic episode. Mania is sometimes referred to as the other extreme to depression. Mania is an intense high where the person feels euphoric, almost indestructible in areas such as personal finances, business dealings, or relationships. They may have an elevated self-esteem, be more talkative than usual, have flight of ideas, a reduced need for sleep, and be easily distracted. The high, although it may sound appealing, will often lead to severe difficulties in these areas, such as spending much more

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money than intended, making extremely rash business and personal decisions, involvement in dangerous sexual behavior, and/or the use of drugs or alcohol. Depression is often experienced as the high quickly fades and as the consequences of their activities becomes apparent, the depressive episode can be exacerbated.

Bipolar II: Similar to Bipolar I Disorder, there are periods of highs as described above and often followed by periods of depression. Bipolar II Disorder, however is different in that the highs are hypo manic, rather than manic. In other words, they have similar symptoms but they are not severe enough to cause marked impairment in social or occupational functioning and typically do not require hospitalization in order to assure the safety of the person.

TreatmentMedication, such as Lithium, is typically prescribed for this disorder and is the corner stone of treatment. Therapy can be useful in helping the client understand the illness and it’s consequences and be better able to know when a manic or depressive episode is imminent and to prepare for this. As with all disorders, poor coping skills and lack of support will make the illness more pronounced, and this is often a focus of therapeutic treatment. PrognosisFor more severe cases, prognosis is poor in terms of ’curing’ the illness, as most people need to remain on medication for their entire lives. The manic episodes may slow down as a result of the natural aging process. With medication, the illness can be kept at a minimum level, with some people not experiencing any overt symptoms for months and even years. However, there are definitely varying degrees of this illness and it is not difficult to misdiagnose due to it's similarity to other mood disorders. If the illness is not severe, often times medication and therapy can do very well in terms of treatment. And, life experience, strong support, and an openness to improve can be enough sometimes to make a difference in outcome.

Adjustment Disorders Common CharacteristicsAll of the disorders in this category relate to a significantly more difficult adjustment to a life situation than would normally be expected considering the circumstances. While it is common to need months and perhaps even years to feel normal again after the loss of a long time spouse, for instance, when this adjustment causes significant problems for an abnormal length of time, it may be considered an adjustment disorder. The disorders in this category can present themselves quite differently. The key to diagnosing is to look at (1) the issue that is causing the adjustment disorder and (2) the primary symptoms associated with the diso

Dissociative Disorders

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Common CharacteristicsThe main symptom cluster for dissociative disorders include a disruption in consciousness, memory, identity, or perception. In other words, one of these areas is not working correctly and causing significant distress within the individual. Dissociative Amnesia CategoryDissociative Disorders EtiologyThis disorder is typically brought on by a traumatic event. SymptomsThe primary symptoms are memory gaps related to traumatic or stressful events which are too extreme to be accounted for by normal forgetting. TreatmentMemory typically returns (and therefore the disorder dissipates) with time. Therapy can be useful to help with coping skills, but is not always needed unless the individual develops excessive fears or worries, or the memory loss has a drastic effect on their everyday functioning. PrognosisPrognosis is extremely good.

Dissociative Identity DisorderFormerly Multiple Personality Disorder CategoryDissociative Disorders

EtiologyDID is associated with severe psychological stress in childhood, most often ritualistic sexual or physical abuse. SymptomsThe primary characteristic of this disorder is the existence of more than one distinct identity or personality within the same individual. The identities will ‘take control’ of the person at different times, with important information about the other identities out of conscious awareness. TreatmentTreatment is difficult for a variety of reasons, including secrecy on the client’s part (unlike the misrepresentation in the media), making him or her reluctant to seek help, and the difficulty in diagnosing the disorder once the client presents. Typically, an individual with DID will require many years of treatment.

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PrognosisBecause the disorder is longstanding, it can be very difficult to treat. Often individuals have numerous ‘ups and downs’ in treatment. Overall, however, extensive work with an experienced therapist can greatly enhance this prognosis.

Eating Disorders

Common CharacteristicsEating disorders are characterized by disturbances in eating behavior. This can mean eating too much, not eating enough, or eating in an extremely unhealthy manner (such as binging or stuffing yourself over and over). Many people argue that simple overeating should be considered a disorder, but at this time it is not in this category. Impulse Control Disorders Common CharacteristicsDisorders in this category include the failure or extreme difficulty in controlling impulses despite the negative consequences. This includes the failure to stop gambling even if you realize that losing would result in significant negative consequences. This failure to control impulses also refers to the impulse to engage in violent behavior (e.g., road rage), sexual behavior, fire starting, stealing, and self-abusive behaviors.

Paraphilias Common CharacteristicsParaphilias all have in common distressing and repetitive sexual fantasies, urges, or behaviors. These fantasies, urges, or behaviors must occur for a significant period of time and must interfere with either satisfactory sexual relations or everyday functioning if the diagnosis is to be made. There is also a sense of distress within these individuals. In other words, they typically recognize the symptoms as negatively impacting their life but feel as if they are unable to control them.

Sexual Disorders and Dysfunctions Common CharacteristicsThe primary characteristic in this category is the impairment in normal sexual functioning. This can refer to an inability to perform or reach an orgasm, painful sexual intercourse, a strong repulsion of sexual activity, or an exaggerated sexual response cycle or sexual interest. A medical cause must be ruled out prior to making any sexual dysfunction diagnosis and the symptoms must be hindering the person's everyday functioning. Gender Identity Disorder has also been placed in this category, although no outward dysfunction needs to be present for this disorder. Basically, it includes strong feelings of being the wrong

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gender, or feelings that your outward body is inconsistent with your internal sense of being either male or femal

Sleep Disorders Common CharacteristicsPrimary Sleep disorders are divided into two subcategories: Dyssomnias are those disorders relating to the amount, quality, and timing of sleep. Parasomnias relate to abnormal behavior or physiological events that occur during the process of sleep or sleep-wake transitions. We use the perm primary to differentiate these sleep disorders from other sleep disorders that are caused by outside factors, such as another mental disorder, medical disorder, or substance use. The primary sleep disorders are listed below: Primary Insomnia CategorySleep Disorders EtiologyPrimary insomnia occurs in up to 10% of adults and up to 25% of elderly adults and appears slightly more common among women. The cause of primary insomnia can be different for each individual but often involves a preoccupation with the inability to sleep or excessive worry about sleep, which in turns causes the individual to not sleep. Many report that they sleep better away from home, suggesting that conditioning related to the bedroom has occurred, and resulting in bouts of sleep while watching TV, being a passenger in a car, or other area not associated with the bedroom. SymptomsThe criteria for a diagnosis of primary insomnia include a difficulty falling asleep, remaining asleep, or receiving restorative sleep for a period no less than one month. This disturbance in sleep must cause significant distress or impairment in social, occupational, or other important functions and does not appear exclusively during the course of another mental or medical disorder or during the use of alcohol, medication, or other substances. TreatmentTreatment often involves relaxation and adhering to a predetermined sleep cycle. The individual sets a schedule of when he or she will sleep and does not allow sleep to occur at any other time. For instance, she may get into bed at 11pm each night and get out of bed at 6am every morning regardless of the amount of sleep that occurs. No sleeping would be allowed during the day and the individual would engage in exercise, healthy eating, and would then use relaxation techniques prior to the scheduled sleep time. Prognosis

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Prognosis is good as the body has a need for sleep and will often adjust to make up for the lack of sleep. When associated with stressors, sleep will often return to normal once the stressors is no longer a significant concern.

Primary Hypersomnia CategorySleep Disorders EtiologyHypersomnia is present in up to 5% of the population at some point in their lives and is more prevalent in males. Causes can vary greatly but often the symptoms begin prior to age 30 and continue to progress unless treated. Some research suggests that sleep disruptions during the night (such as breathing related sleep disorder) causes the individual to lack REM sleep and therefore feel tired despite the fact that he or she has slept through the night. SymptomsThe criteria for primary hypersomnia include excessive sleepiness for at least one month as evidences by prolonged sleep during the night or excessive daytime sleep. This must cause significant distress or impairment for the individual and can not occur exclusively during another mental illness, medical condition, or substance use. TreatmentTreatment can include medication, exercise, changes in diet or other techniques employed to treat associated disorders if present (e.g., breathing related sleep disorder). If associated with another mental (e.g., depression) or medical condition the symptoms of primary hypersomnia will often dissipate went the other condition improves. PrognosisHypersomnia can be chronic, especially when not associated with another disorder and therefore can continue to worsen if left untreated. Treatments are readily available and can improve the prognosis significantly.

Narcolepsy Category

Sleep Disorders

Etiology

SymptomsNarcolepsy is diagnosed when an individual has repeated sudden occurrences of sleep for a period of at least three months. To be diagnosed, at least one of the following must be present: cataplexy

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(brief episodes of sudden loss of muscle tone) and REM intrusions (REM sleep occurs at unexpected times and results in hallucinations or sleep paralysis). These symptoms can not be the result of another mental disorder, a medical condition, or the use of substances.

Psychotic Disorders (including Schizophrenia) Common CharacteristicsThe major symptom of these disorders is psychosis, or delusions and hallucinations. Delusions are false beliefs that significantly hinder a person's ability to function. For example, believing that people are trying to hurt you when there is no evidence of this, or believing that you are somebody else, such as Jesus Christ or Cleopatra. Hallucinations are false perceptions. They can be visual (seeing things that aren't there), auditory (hearing), olfactory (smelling), tactile (feeling sensations on your skin that aren't really there, such as the feeling of bugs crawling on you), or taste.

Brief Psychotic Disorder CategoryPsychotic Disorders EtiologyThe cause of this disorder is typically an extremely stressful event or trauma. SymptomsPresence of psychotic symptoms (delusions, hallucinations, disorganized speech, and/or disorganized behavior) which lasts at least one day but no more than one month. TreatmentSupportive therapy or interpersonal relationships and at times medication. PrognosisVery good. By definition, the disorder will resolve itself within one month. If the symptoms last more than one month, the diagnosis needs to be reconsidered as does prognosis.

Schizophreniform CategoryPsychotic Disorders EtiologySchizophreniform is typically used as a preliminary diagnosis for schizophrenia. Due to the complexities of schizophrenia, an initial diagnosis is very often tentative and schizophreniform is therefore used. Symptoms

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See Schizophrenia.

TreatmentMedication is the most important part of treatment as it can reduce and sometimes eliminate the psychotic symptoms. Case management is often needed to assist with daily living skills, financial matters, and housing, and therapy can help the individual learn better coping skills and improve social and occupational skills. PrognosisIf the symptoms are not significantly reduced in the first six months after diagnosis, a change of diagnosis to schizophrenia is warranted. By definition, schizophreniform can not be diagnosed for a period longer longer than six months.

Schizophrenia CategoryPsychotic Disorders EtiologyMany theories have been introduced in an attempt to explain this disorder. Currently, most professionals believe it is a result of a physiological condition brought out by a life stressor. SymptomsSymptoms of Schizophrenia typically begin between adolescence and early adulthood for males and a few years later for females, and usually as a result of a stressful period (such as beginning college or starting a first full time job). Initial symptoms may include delusions and hallucinations, disorganized behavior and/or speech. As the disorder progresses symptoms such as flattening or inappropriate affect may develop. See Schizophreniform for more information on diagnoses. TreatmentMedication is the most important part of treatment as it can reduce and sometimes eliminate the psychotic symptoms. Case management is often needed to assist with daily living skills, financial matters, and housing, and therapy can help the individual learn better coping skills and improve social and occupational skills. PrognosisThere is no cure for this disorder so prognosis is poor. However, medication has been shown to be quite effective against the psychotic symptoms and therapy can help the individual cope with the illness better and improve social functioning. Absence of what is termed the negative symptoms (flattened affect, avolition, and poor social interaction) improves the prognosis significantly. Somatoform Disorders Common Characteristics

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Disorders in this category include those where the symptoms suggest a medical condition but where no medical condition can be found by a physician. In other words, a person with a somatoform disorder might experience significant pain without a medical or biological cause, or they may constantly experience minor aches and pains without any reason for these pains to exist. Substance Related Disorders Common CharacteristicsThe two disorders in this category refer to either the abuse or dependence on a substance. A substance can be anything that is ingested in order to produce a high, alter one's senses, or otherwise affect functioning. The most common substance thought of in this category is alcohol although other drugs, such as cocaine, marijuana, heroin, ecstasy, special-K, and crack, are also included. Probably the most abused substances, caffeine and nicotine, are also included although rarely thought of in this manner by the layman.

Personality DisordersCommon CharacteristicsPersonality Disorders are mental illnesses that share several unique qualities. They contain symptoms that are enduring and play a major role in most, if not all, aspects of the person's life. While many disorders vacillate in terms of symptom presence and intensity, personality disorders typically remain relatively constant. To be diagnosed with a disorder in this category, a psychologist will look for the following criteria:

1. Symptoms have been present for an extended period of time, are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder. The history of symptoms can be traced back to adolescence or at least early adulthood.

2. The symptoms have caused and continue to cause significant distress or negative consequences in different aspects of the person's life.

3. Symptoms are seen in at least two of the following areas: o Thoughts (ways of looking at the world, thinking about self or others, and

interacting)o Emotions (appropriateness, intensity, and range of emotional functioning)o Interpersonal Functioning (relationships and interpersonal skills)o Impulse Control

Paper-3

Fundamentals of nursing

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Syllabus: as per gujarati book

Question bank:

PAPER - I - FUNDAMENTALS OF NURSING, PHARMACOLOGY AND MICROBIOLOGY

I. DEFINEUnit-1

Mother of modern nursing Lady with the lamp International nurses dayUnit-2

Hospital small hospital Maternity homeICU medium hospital Paediatric hospitalmedical hospital large hospital Cardiac hospitalOPD government hospital radiology departmentisolation ward pathology department anaesthetistnurse nursing superintendent CSSD

Unit-3

disease bedpan social needMicro organism elimination need spiritual neednutritional need diarrhoea medication need

Unit-4

cotton ring Hot water bag sand bagair mattress mackintosh recovery bedwater mattress dr sim's position fracture bedice cap high fowler position supine positioncardiac bed amputation bed lithotomy positionfowlers bed prone position trendlenburg position

Unit-5

micro organism cross infection contaminationinfection disinfection terminal disinfectionmedical asepsis intestinal /enteric isolation droplet infectionsterilization autoclaving surgical asepsis

Unit-6

foliz catheter medicine glass thermometerforceps syringe scissorkidney tray sponge holder needle holder

Unit-7

routine admission DAMA mechanical injury

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emergency admission DOR thermal injuryradioactive injury D&T to other hosp chemical injuryseptic injury MLC electrical injury

Unit-8

congenital disease deficiency disease cyanosisophthalmoscope malnutrition palpationautoscope diagnosis percussionnasal speculum sphygmomanometer auscultationvital signs stethoscope thermometer

Unit-9

Temperature clinical thermometercentigrade and Fahrenheit formula

Pulse rectal thermometer thermolysisRespiration normal temperature thermo genesisBlood pressure pyrexia normal respiration raterate of pulse inspiration cyanosistachycardia expiration blood pressurebrady cardia rate of respiration hypertensiondyspnoea pulse pressure normal Blood pressure

Pathology nursing

CBC S.Widal PP2BSMP LFT RBSSGPT FBS NPONBM pecimen investigation

x-ray

ultrasonic scan MRI LaproscopyUSG CT scan bronchoscopycolonoscopy x-ray gastroscopy

Oxygen administration

Asphyxia regulator cynosisflow meter pressure meter woll'f bottle

Elimination

defecation dysentery retention enemaenema typhoid small enemadehydration food poisoning large enemasoap water enema nutrition enema medicinal enemaice water enema sedative enema anaesthetic enema

Hot and cold fomentation

46

hot application endodermis sit's bathcold application functions of skin poulticesskin hydrotherapy steam bathdermis hot water bag cold compresscold pack tepid sponge

Unit-13

Pint Hole sheet inj ProstodinVein flow vacuum inj zobidScalp suction machine inj rantacSponge holder EDT bulb inj epidosinForceps Suction Canula inj cintocinSpeculum Dilator inj pitocinGloves inj Methargin inj ondasetronKidney tray Cord clamp Scissor

Pharmacology

Pharmacology pint s.o.s.sublingual administration ounce t.d.s.Instillation O.D. b.d.Subcutaneous sc statIntravenous IM h.s.Tranquillizer IV side effectAppetizer antipyretic over doselaxative Antibiotic Antacid

Injection

expiry date whole blood Blood grouplocation of IM injection Pack cell Rh factorBT venous cut down Cross infectionDNS Universal donor blood group Universal recipient blood group

Surgical nursing

Cosmetic surgery Transfusion SurgeryTransplant OT Major surgeryTransfusion OR NG tubeEmergency surgery NPO general anaesthesiaDiagnostic surgery NBM spinal anaesthesia

Surgical instruments

scissor chromic suture towel clipstraight mayo vicryl suture retractorcurved mayo catgut suture DAMAmosquito OT table discharge

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thumb forceps OT light scrub nursetissue forceps informed consent circulatory nurse

Personal hygiene

Gingivitis Head bath TonsilitisParotitis Bedsore AnorexiaStomatitis Pyrrhoea Bed bath

Short and detailed questions

1. Life of Florence nightingale 2. Write and explain pledge of Florence nightingale nie>T)>gln) p\(tXi lK) (vgtvir

smjivi[3. various functions of hospital in details hi[(ApTlni kiyi[>4. classification of hospital hi[(ApTln& vg)<krN5. classification of hospital wards hi[(ApTl vi[D<n& vg)<krN6. Emergency wards7. Various departments of hospital and their importance hi[(ApTlni (v(vF (DpiT<m[ºT

an[ t[n& mhRv8. Various health team members and their duties (v(vF h[ÃYT)m m[Àbs< an[ t[ni

kiyi[<9. Causes of disease ri[g Yvini kirNi[ n& vg)<krN10. Various needs of the patient 11. Explain morning-evening and bedtime care of the patient 12. List some mechanical devices to promote comfort to the patient (comfort devices)

hi[(ApTlmi> apiti airim vFirvi miT[ni k>fi[T< D)vies pr ni[>F lKi[13. Explain bed making in details14. Classification of various bed15. Various positions in hospital16. Various isolation techniques17. Various sterilization techniques in hospital18. Various discharge methods in the hospital19. Various injuries in the hospital20. Explain vital sign. Explain procedure taking TPR vieTl sien smjiv) TPR l[vin) p¹F(t

smjivi[21. Explain BP taking method with drawing aikZ(t siY[ BP mipvin) p¹F(t smjivi[22. Explain thermometer with drawing 23. Oral temperature and rectal temperature indications and contra indications ai[rl T[Àpr[cr

an[ r[kTl T[Àpr[cr kyir[ l[vi an[ kyir[ n le Skiy t[ (vgtvir smjivi[.24. Explain various urine and blood tests25. X-ray technique

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26. Explain modern techniques of radiology with comparisons i.e. CT scan, USG , MRI and Endoscopy . CT scan, USG , MRI an[ Endoscopy j[v) aiF&(nk r[D)yi[li[J T[kn)k n) srKimN) kr) (vgti[ smjivi[

27. Draw oxygen bottle and explain functions of all parts ai[(ksjn bi[Tl di[r) dr[k Bigni kiyi[< smjivi[

28. Explain various oxygen administration methods and indication of oxygen administration ai[(ksjn kyir[ aipvi[ pD[ t[ s>ji[gi[ smjiv) ai[(ksjn aipvin) (v(vF p¹F(t smjvi[

29. Various types of enema30. Explain constipation in details31. Explain diarrhea in detail32. Explain various cold applications on skin33. Explain various hot applications on skin34. Explain various diet plan for sick mi>di Äy(kt miT[ (v(vF DiyT ¼lin smjivi[35. Explain various tube feeding methods with drawing aikZ(t siY[ (v(vF Ty&b f)D)>g

p¹F(t smjivi[36. Importance of five rights during medicine administration dvi aipt) vKtn) pi>c sic)

bibti[n& mhRv smjivi[37. Form of drugs. i.e. tab, syrup etc.. dvini p\kir di.t. tab, syrup vg[r[38. Draw and explain injection39. Classification of injection 40. Administration of IV injection41. Indication and administration of BT ¾lD T^i>Afy&znn) j$r)yit an[ p¹F(t42. Preoperative care 43. Classification of surgeries 44. Bedsore: definition, causes and management b[Dsi[r: Äyi²yi, kirNi[ an[ sirvir45. Bed bath46. Importance of personal hygiene and various personal hygiene care of patient

hi[(ApTlmi> a>gt t>d&rAt)n& mhRv an[ (v(vF personal hygiene p¹F(tai[

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Paper-4

First aid and Emergency techniques

First aid

crushed wound First aider Shockstab wound closed fracture faintingfracture open fracture woundcomplicated fracture pain crack fractureimpacted fracture Oedema direct force fracturedepressed fracture tenderness indirect force fracturecrepitus Paralysis Burn

Emergency techniques

Emergency nurse casuality ICUIPCU NICU ICCUMICU SICU DisasterTrauma care Penetrating trauma biotransitionCPR EFGHI Endotrachial intubationNosotrachial intubation hypovolemia SVRCNS RS CVSHypothermia Shock Peritoneal lavageOxygen Debt Dilutional coagulopathy HaemothoraxPneumothorax Pulmonary contuser Fat ambolismARDS DVT MODS

First aid

1. Explain importance of first aid and qualities of first aider fAT< a[eDn& mhRv smjiv) fAT< a[EDrni g&NFmi[< smjivi[

2. Explain fracture with its types and first aid (v(vF f\[kcrni p\kir an[ f\[kcrn) fAT< a[eD smjivi[

3. Explain various wounds and their first aid (v(vF wound an[ t[n) fAT< a[eD smjivi[

4. Explain various hemorrhage and their first aid (v(vF h[mr[jni p\kir an[ t[n) fAT< a[eD smjivi[

Emergency care

1. Role of emergency nurse

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2. Explain casuality ward in details3. Explain regarding various ICUs4. Write notes on ICU setting5. Types of trauma and ICU management6. Explain CPR7. Explain various airway opening methods8. Notes on three response patterns9. Explain ICU management of following conditions

a. Chest injuryb. Rib cage fracturesc. Head injuriesd. Abdominal injuries

10. Notes on Fat ambolism

EMERGENCY NURSE

Background:

Emergency nurses specialize in rapid assessment and treatment when every second counts, particularly during the initial phase of acute illness and trauma. Emergency nurses must tackle diverse tasks with professionalism, efficiency, and above all—caring.

Emergency nursing is a specialty area of the nursing profession like no other. To provide quality patient care for people of all ages, emergency nurses must possess both general and specific knowledge about health care to provide quality patient care for people of all ages. Emergency nurses must be ready to treat a wide variety of illnesses or injury situations, ranging from a sore throat to a heart attack.

There are approximately 90,000 emergency nurses in the US.

Roles:

Patient Care—Emergency nurses care for patients and families in hospital emergency departments, ambulances, helicopters, urgent care centers, cruise ships, sports arenas, industry, government, and anywhere someone may have a medical emergency or where medical advances or injury prevention is a concern.

Education—Emergency nurses provide education to the public through programs to promote wellness and prevent injuries, such as alcohol awareness, child passenger safety, gun safety, bicycle and helmet safety, and domestic violence prevention.

Leadership and Research—Emergency nurses also may work as administrators, managers, and researchers who work to improve emergency health care.

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Prehospital Care and Transport The time from injury to definitive care is a determinant of survival, particularly those with

major internal hemorrhage. Careful attention must be given to the airway with cervical spine immobilization, breathing

and circulation. (ABC’s) Full spinal mobilization is being challenged and reexamined: Asking: Is full spinal mobilization necessary in all trauma patients? How appropriate is the assessment of prehospital assessment? Concerns over the high false positive rate that occurs with prolonged spinal immobilization.

Current Guidelines

Objectives Explain emergency care as a collaborative, holistic approach that includes patient, family

and significant others. Discuss priority emergency measures for any patient with an emergency situation. Discuss pre-hospital, emergency care and resuscitation of the trauma patient.

Objectives• Discuss disaster triage concepts and contrast with traditional triage concepts.

Trauma The fourth leading cause of death for ALL ages Nearly ½ of all traumatic incidents involve the use of alcohol, drugs or other substance

abuse. Is predominantly a disease of the young and carries potential for permanent disability.

Systems Approach to Trauma An organized approach to trauma care that includes: Prevention, access, acute hospital care, rehabilitation, and research

Trimodal Distribution of Death First peak- seconds to minutes from time of injury to death—severe injuries: lacerations of

the brain, brainstem, high spinal cord, heart aorta, large blood vessels. Second peak- minutes to several hours: subdural, epidurdal hematomas,

hemopneumothorax, ruptured spleen, lacerated liver, pelvic fractures, other injuries associated with major blood loss.

Third peak-occurs several days to weeks after the initial injury: most often the result of

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sepsis and multiple organ failure. At this stage, outcomes are affected by care previously provided.

Levels of Trauma Care American college of Surgeons Committee on Trauma Level’s I-IV, Level ones are the most sophisticated and care for all aspects from prevention to

rehabilitation.

Trauma Triage Minor trauma: single system injury that does not pose threat to life or limb and can be

appropriately treated at a basic emergency facility. Major trauma: serious multi system injuries that require immediate intervention to prevent

disability.

Mechanism of injury Is vital to the initial assessment and may raise suspicions about the patients injury pattern. Blunt vs. penetrating injury

Blunt Trauma Most often results from vehicular accidents, but may occur in assaults, falls from heights, and

sports related injuries. May be caused by accelerating, decelerating, shearing, crushing, and compressing forces. Coup-contra coup injury Body tissues respond differently to kinetic energy…low density porous tissues and structures,

such as lungs, often experience little damage because of their elasticity. The heart , spleen and liver are less resilient often rupturing or fragmenting. Often, overt external signs are not apparent…making the mechanism of injury most important

to the practitioner performing the physical examination.

Penetrating Trauma Results from the impalement of foreign objects into the body More easily diagnosed because of obvious injury signs. Stab wounds are usually low velocity…the direct path, the depth and width determine injury. Women tend to have trajectories in a downward motion, men in an upward force. Ballistic trauma may be either low or high velocity injuries. Missiles or bullets that come into contact with internal structures that produce a change in in

pathway release more energy and result in more injury than a direct pathway. Injuries sustained from penetrating objects must be assessed for the potential for infection

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from the debris carried by the penetrating object.

Disaster / Mass Casualty Triage Concepts Most severe injuries in mass trauma events are fractures, burns, lacerations, and crush injuries. Most common injuries are eye injuries, sprains, strains, minor wounds and ear damage. (CDC

Website)

Mass Casualty: Who is at risk? Anyone in surrounding area. Rescue workers and volunteers.

Bioterrorism Agents/Diseases, Threats CDC Website ( see handout)

Pre-Hospital Care and Transport The time from injury to definitive care is a determinant of survival. Careful attention is given to C-spine immobilization, breathing and circulation…(ABC’s)

CurrentGuidelineson C-Spine Immobilization Although it has been challenged, C-spine immobilization is still the protocol for trauma patients

until diagnostically cleared (X-Ray)

Additional Pre-Hospital Measures Occlusive dressings to open chest wounds Needle thoracotomy to relieve tension pneumothorax Endotracheal intubation Cricothyrtomy

Caveat!!! Research has indicated INCREASED mortality with IV fluids BEFORE hemorrhage control. Transport is not delayed to start IV access!

Transport How is it decided? Travel time Terrain Availability of air or ground transport Capability of personnel

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Weather

Emergency Care Phase Preparation Trauma team at receiving hospital responds before arrival of patient Report has been transmitted Preparations are initiated based on report.

Initial Patient Assessment Clinical presentation Physical assessment History of traumatic event Pre-existing illness

Primary Survey Most crucial assessment tool in trauma care 1-2 minutes MAX! Designed to identify life threatening injuries ACCURATELY Establish priorities Provide simultaneous therapeutic interventions.

Resuscitation Phase Secondary Survey: Table18:2 page 647/648 32

EFGHI = E- Expose the patient F- *Full set of vital signs, *five interventions (cardiac monitor, pulse oximetry, urinary catheter,

NG if not contraindicated, lab studies) G- giving comfort measures…pain control, reassurance to patient and family H- history/ head to toe assessment I- inspect for hidden injuries-log roll patient to inspect posterior aspect.

Sequence of Diagnostic Procedures Influenced by: Level of consciousness Stability of patient’s condition Mechanism of injury Identified injuries

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Maintain Airway Patency Essential to trauma management EVERY trauma patient has potential for airway obstruction Most common obstruction: Tounge Other common causes: blood or vomitus, secretions, structural impairment, depressed

sensorium, absent gag reflex

How to open the airway? Jaw thrust or chin lift!!! These maneuvers do not hyperextend the neck or compromise the integrity of the C-spine

Maintaining the airway Simple, simple!! Nasopharyngeal airway Oropharyngeal airways

Definitive Nonsurgical Airway Endotracheal intubation-Complete control of the airway Nasotracheal intubation—INDICATED for the spontaneously breathing

patient..CONTRAINDICATED in the patient with facial, frontal sinus, basilar skull or cribriform plate fractures.

Choice of Airway management Familiarity of procedure Clinical condition of the patient Degree of hemodynamic stability

A PATENT AIRWAY IS THE CORNERSTONE OF SUCCESSFUL TRAUMA RESUSCITATIONA LIFE THREATENING CONDITION EXISTS Altered mental status (agitation) Cyanosis ( nail beds and mucous membranes) Asymmetrical chest expansion Use of accessory muscles/abdominal muscles Sucking chest wounds Paradoxical movements of the chest wall Tracheal shift Distended neck veins Diminished or absent breath sounds

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Impaired Gas Exchange Follows airway obstruction as the nest most crucial problem for the trauma patient Reasons: decreased inspired air, retained secretions, lung collapse or compression, atelectasis,

accumulation of blood in the thoracic space.

Decreased Cardiac Output/Hypovolemia Acute Blood loss—MOST common cause in acute trauma May be external or internal

Treatment PASG- anti-shock garment (pneumatic anti-shock garment) When inflated, PASG compresses the legs and abdomen, resulting in increased venous return

and SVR(systemic vascular resistance) preventing further blood loss into the abdomen and legs. Elevates systemic pressure by shunting a small amount of blood into central circulation CAN be a detriment, elevates BP, and in the event of hemorrhage without DEFINITIVE control

can be fatal.

Additional Causes of Decreased Cardiac Output (Impaired venous return to the heart) Tension Pneumothorax Pericardial Tamponade (from decreased filling and ventricular ejection fraction)

Table 18-4 Pay attention to Class I through IV *EBL (estimated blood loss) *Changes in pulse, BP, RR, UOP, mental status. Note the fluid/blood needed to replace: 3:1 rule

Priority Interventions Patent airway Maintaining adequate ventilation Adequate gas exchange Then: Control hemorrhage, replace circulating volume, restore tissue perfusion

Control of External Hemorrhage Direct Pressure Elevation Compression of pressure points (arteries, veins) AVOID tourniquets…can compromise loss of circulation and loss of limb

Control of Internal Hemorrhage Identification and correction of underlying problem

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Fluid Resuscitation Venous Access and Volume infused are key Two large bore IV’s 14-16 gauge. (Never less that 18, that is the smallest to give blood through

rapidly and not have hemolysis) Forearm and anti-cubital veins are preferred Central lines are more beneficial as resuscitation MONITORING tools A pulmonary artery catheter may be inserted in the critical care unit to monitor volume. RULE: Venous access with largest bore catheter possible. Isotonic fluids are used INITIALLY Ringer’s Lactate is first choice followed by Normal Saline Large bore catheters, short tubing, rapid infuser devise that warms fluids and blood. An initial bolus of 2 liters of fluid is used unless there is contraindication… 3:1 rule= 3mls of crystalloid for each 1ml of blood loss. INITIAL response to fluid challenge is urine output..should =50 ml in adult, LOC, heart rate, BP

and capillary refill.

Three Response Patterns Rapid Response- respond quickly to fluid challenge and remains stable at completion of

bolus. Transient Response- responds quickly but declines when fluids are slowed

(indicates continued blood loss)

Non Response-

fail to hemodynamically respond to crystalloid and blood…require immediate surgical intervention.

See table 18-5 on page 652

Decision to give Blood Based on patients response to initial fluid ** if unresponsive to fluid, type specific blood is given, IF LIFE THREATENING…may give O

positive. ***Crossmatched, type specific should be given as soon as possible.

Auto-transfusion Collection of blood from the patients intra-thoracic injuries is anti-coagulated and filtered and

administered to the patient.

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SAFE, carries no compatibility problems, no risk of transmitted disease.

During resuscitative phase Imperative to locate etiology of hemorrhage: Chest and pelvis, extremity X-rays Abdominal ultrasound Abdominal CT can be used but in the case of hemodynamic instability Peritoneal lavage is the

quick, invasive test of choice

Peritoneal Lavage Insertion of lavage catheter directly into the abdomen Aspiration of greater than 10 mls blood and patient goes directly for surgery. If less than 10 mls of blood, 1 liter of warmed NS is infused into peritoneal cavity, then drained

and sent for cell counts, amylase, bile, food particles, bacteria, fecal matter.

Hypothermia Defined as a core temp of 35 degrees Centigrade Can occur year round More susceptible person: older, using alcohol or sedatives, severe injury, massive transfusions. In presence of cooler atmospheric temps Submersion in water Rapid infusion of room temp. IV fluids Effects the myocardium and the coagulation system. Can result in bradycardia, atrial and ventricular fibrillation

Treatment Warm fluids Warming blankets Overhead warmers

Ongoing Signs and Symptoms of Shock Decreased H&H Deterioration of PaO2 and pH Rising base deficits Diminished UOP (less than >.5ml/kg/hr) Increasing Lactate levels

Unreliability of H&H Can take up to 4 HOURS!! To re-equilibrate, therefore cannot gauge degree of shock.

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On-going metabolic acidosis Result of hypovolemia and hypoxia Indicates inadequate tissue perfusion Indicates anaerobic metabolism—very inefficient cellular metabolism. Must be interrupted or cellular dysfunction results in cellular swelling, rupture and death.

Massive Fluid Resuscitation Greater than 10 units of PRBC’s over 24 hours or the replacement of the patient’s total blood

volume in less than 24 hours. It is associated with VERY poor outcomes. Purpose is to restore oxygen transport to the tissues, stop the progression of shock, prevent

complications.

Potential Complications of Massive Fluid Resuscitation Acid base imbalances Electrolyte imbalances Hypothermia Dilutional coagulopathies Volume overload SIRS (systemic inflammatory response syndrome) ARDS (acute respiratory distress syndrome) MODS (multi-organ dysfunction syndrome)

Oxygen Debt Result of metabolic acidosis—shift from aerobic to anaerobic metabolism resulting in

accumulation of lactic acid…hence…lactic acidosis. MUST REVERSE to prevent cellular death

Electrolyte Imbalances Hypocalcemia Hypomagnesemia Hyperkalemia May lead to changes in myocardial function, laryngeal spasm, neuromuscular and central

nervous system hyperirritability

Third Spacing Vessels become more permeable to fluids and molecules, leading a change in movement from

the intravascular space to the interstitial space. Patients become more hypovolemic requiring more fluid replacement.

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Dilutional Coagulopathy Dilutional thrombocytopenia Reduced fibrinogen Reduced factor V, FactorVIII and other clotting components High levels of citrate in blood products reduce calcium…leading to an ineffective clotting

cascade (calcium is a necessary co-factor for this process). Platelet dysfunction can occur secondary to hypothermia or metabolic acidosis

Treatment of Dilutional Coagulopathy Improve tissue perfusion Resolve hypothermia Administer clotting factors (FFP, cryoprecipitate, platelets) Monitor labs (H&H, PLT count, fibrinogen, PT, PTT

Changes in the Coagulation Cascade Initially helpful…release of inflammatory mediators…over time (can be a fairly short time) can

result in SIRS, ARDS, MODS

Assessment and Management of specific Organ Injuries Chest Injuries Spinal Cord Injuries Head Injuries Musculoskeletal Injuries Abdominal Injuries

Chest Injuries Tension Pneumothorax- is rapidly fatal Easily resolved with early recognition and intervention Air enters the pleural cavity without a route of escape, with each inspiration, additional air Enters the pleural space, INCREASING intrathoracic pressure causing collapse of the lung The increased pressure causes pressure on the heart and great vessels compressing them

TOWARD the unaffected side. Physical evidence: Mediastinal Shift & distended neck veins. RESULTS in: decreased Cardiac Output and alterations in gas exchange Manifested by: severe resp. distress, chest pain, hypotension, tachycardia, absence of breath

sound son affected side, and tracheal deviation Cyanosis is a LATE manifestation.

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Tension Pneumo cont… Diagnosis based on CLINICAL presentation not Chest x-ray Treatment is never delayed to confirm by X-ray Immediate decompression with a 14 gauge needle (thoracostomy)..inserted at the 2nd

intercostal space at the midclavicular line on the INJURED side. This converts a tension pneumo to a simple pneumo. Definitive treatment then requires placement of a chest tube.

Hemothorax Collection of blood in the pleural space From injuries to the heart, great vessels, or pulmonary parenchyma Signs and symptoms: decreased breath sounds, dullness to percussion on affected side,

hypotension, respiratory distress. Treatment: Placement of chest tube.

Open Pneumothorax Results from penetrating trauma that allows air to pass IN AND OUT of the pleural space Patient presents with hypoxia and hemodynamic instability Management: Three sided occlusive dressing…fourth side is LEFT OPEN to allow for exhalation

of air from the pleural cavity. IF the dressing is occluded on all four sides the patient may develop a tension pneumothorax. Treatment: Chest tube placement

Cardiac Tamponade Life threatening condition caused by RAPID accumulation of fluid (usually blood) in the

pericardial sac As intra-pericardial pressure increases, cardiac output is impaired because of decreased venous

return. Classic signs are: BECK’s Triad: muffled or distant heart sounds, hypotension, elevated venous

pressure…and may not present until the patient is hypovolemic and hypotensive. Pulsus paradoxus= a decrease in systolic blood pressure during spontaneous respiration. Causes: penetrating trauma to chest, blunt trauma to chest. Diagnosed with FAST ( focused abdominal sonography or pericardiocentesis—don’t with 16 or

18 gauge cath over needle and 35 ml syringe and 3 way stopcock) Aspirated pericardial blood usually will not clot unless the heart has been penetrated. Arterial BP can dramatically improve with as little as 15-20 ml of blood removed. Nurses should anticipate and prepare for pericardiocentesis in the event of cardiac arrest.

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Pulmonary Contusion Results from blunt or penetrating trauma to the chest One of the most common causes of death after trauma Predisposes the patient to pneumonia and ARDS. Can be difficult to detect.

May not be seen on initial X-ray Infiltrates and hypoxemia may not occur for hours of days. Clinical presentation includes: chest abrasions, ecchymosis, bloody secretions, PaO2 of

60mmHG or less on room air. Often associated with flail chest and rib fractures The bruised lung becomes edematous, resulting in hypoxia and respiratory distress Treatment is ventilatory support, careful fluid administration, pain management.

Rib Fractures Most common injury after chest trauma Rib fractures usually dx’d by xray, but can be clinically dx’d HIGH IMPACT force is needed to fracture the 1st and 2nd ribs. Clinically look for major vessel

injury.. Injury to the liver spleen and kidneys should be considered with fracture of ribs 10-12 Treatment: Depends on ribs Fx’d and age of patient. Elderly with multiple rib fx may require

hospitalization.

Patient Teaching is very important:

DO NOT restrict chest movement, pain control, ambulation.

Flail Chest Usually caused by blunt force trauma, EX: Chest hits steering wheel. Three or more adjacent ribs are fractured. Flail section floats freely resulting in paradoxical chest movement. Flail section contracts INWARD with inspiration and expands OUTWARD with expiration. Treatment: Intubation/mechanical ventilation, frequent pulmonary care, aggressive pain

management.

Aortic Disruption Produced by blunt trauma to the chest Ex: rapid deceleration from head-on MVA, ejection, or falls. Four common sites of dissection: the left subclavian artery at the level of the ligamentum

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arteriosum, the ascending aorta, the lower thoracic aorta above the diaphragm, and avulsion of the innominate artery at the aortic arch.

Signs: weak femoral pulses, dysphagia, dyspnea,hoarsness, pain. Chest x-ray shows wide mediastinum(greater or equal to 8mm), tracheal deviation to the right,

depressed mainstem bronchus, first and second rib fractures, left hemothorax. CONFIRMATION is done with aortogram Treatment is SURGICAL

Spinal Cord Injury Mechanism of injury can be: hyperflexion, hyperextension, axial loading, rotation, penetrating

trauma Initially: ABC’s, immobilization Triage to appropriate facility Complete sensory &motor neuro exam Lateral C-Spine films, possible Spinal CT to rule out occult fracture. Dislocations of the spine are reduced ASAP Postural reduction with tongs, halo traction or surgical fusion. IV methylprednisolone within 8 hours Spinal Shock= loss of sympathetic output=Neurogenic shock results are bradycardia,

hypotension. Need vasopressors to compensate for loss of sympathetic innervation and resultant

vasodilatation. Potential Complications: GI dysfunction, autonomic dysreflexia, DVT, orthostatic hypotension,

loss of bowel and bladder function, immobility, spasticity, and contractures. THINK EARLY PREVENTION AND INTERVENTION!!!!

Head Injury Can be caused by blunt or penetrating trauma. Lacerations to the scalp produce profuse bleeding. Fractures of the skull may have underlying brain injury

Basilar skull fractures are located at the base of the cranium and potentially involve 5 bones that form the base of the skull. Are diagnosed based on the presence of CSF in the nose (rhinorrhea) or ears (otorrhea) Basilar Skull Fracture cont… Ecchymosis over the mastoid (Battle’s sign) Hemotympanium (blood in the middle ear) Raccoon eyes or periorbital eccymoses =cribiform plate fracture Potential complications of Basilar Skull Fractures: Infection and cranial nerve injury.

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Secondary Head Injury Refers to the systemic (hypotension, hypoxia, anemia, hypocapnia, hyperthermia) or

intracranial ( edema, intracranial hypertension, seizures, vasospasm) changes that result in alteration in the nervous system..page 657..read this!!! Very important.

Prehospital MOST important Supplemental oxygen, often intubation Aggressive and careful volume replacement ICP monitoring/ Goal is 20mm Hg Cerebral Perfusion Pressure=MAP(mean arterial pressure) Minus Mean ICP and keep at 70mm

Hg to decrease neurological disability. Osmotic and loop diuretics, CSF drainage, hyperventilation (results in vasoconstriction of

cerebral vessels allowing more space for swelling brain tissue), paralysis WITH sedation, pentobarbital induced coma is final intervention when all else fails.

Nursing Care for Traumatic Head Injury Airway, adequate ventilation and gas exchange, clearance of pulmonary secretions, proper

head alignment, close neurological function monitoring. Pulmonary complications are common, aggressive pulmonary hygiene HOB at 30 degrees Assess for intracranial hemodynamics(ICP and perfusion pressure) and patient tolerance

Musculoskeletal Injuries See Types of Fractures Table 18-7 on page 658 Extremity Assessment= the 5 P’s Pallor pain, pulses, parethesia, paralysis (describes the neurovascular status of the injured

extremity. When possible the injured extremity if compared with the non-injured extremity Fracture wounds should be debrided and the fracture reduced within 18 hours to prevent

infection and nonunion. If hemodynamically unstable, skeletal traction to realign the extremity may be used . Unstable Pelvis fractures can be life threatening secondary to potential for severe hemorrhage,

exsanguination, damage to genitourinary system and sepsis.

Traumatic Soft Tissue Injury Categorized as: contusions, abrasions, lacerations, punctures, hematomas, amputations, and

avulsions. All wounds are considered contaminated. Tetanus Toxoid and antibiotics are always CONSIDERED.

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Complications of Musculoskeletal Injuries Rhabdomolysis-a complication of crush injuries—marked vasoconstriction and hypotension

followed by ARF

Results from muscle destruction

Myogolobin and potassium are released from the damage muscles

Can result in life threatening hyperkaemia.

Myoglobin excreted through the urine, combined with hypovolemia, produces ARF and ATN if not aggressively treated.

Treatment= Aggressive saline replacement, alkalinization of urine, osmotic diuresis.

Compartment Syndrome Places the patient at risk for limb loss. More common in the legs and forearms but can occur other places. The closed muscle compartment contains neurovascular bundles tightly covered by fascia. An increase in pressure within that compartment produces the syndrome. Internal sources= hemorrhages, edema, open or closed fractures, crush injuries External sources=PASG’s, casts, skeletal traction, air splints. The pain is described as throbbing appearing DISPROPORTIONATE TO THE INJURY. Increases

with muscle stretching. The affected area is firm to touch. Paresthesia distal to the compartment, pulselessness, and paralysis are LATE signs.

Treatment s immediate surgical fasciotomy.

Fat Embolism

Usually associated with long bone, pelvis, and multiple fractures.

Usually develops within 24 to 48 hours after injury.

Hallmark clinical signs: low grade fever, new onset tachycardia, dyspnea, increased resp rate and effort, abnormal ABG’s, thrombocytopenia and petechiae.

Development of lipuria (fat in the urine) indicates severe fat embolism syndrome. Prevention is the best treatment. Treatment is directed at preserving pulmonary function and maintenance of cardiovascular

function. Careful attention to EKG changes. See Box 18-2 on page 660 IMPORTANT!!!

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Abdominal Injuries The Classic sign is PAIN. But may be obscured by AMS, drug or alcohol intoxication, Spinal cord Injury with impaired

sensation The liver is the most commonly injured organ from blunt or penetrating trauma Liver injuries are graded I through VI. Splenic injury most commonly occurs from blunt trauma but can be caused by penetrating

trauma. Presentation: LUQ tenderness, peritoneal irritation, referred pain to the left shoulder (Kerr’s

sign) Graded I to V. Diagnosed with FAST, Abd. CT or peritoneal lavage. Patients more at risk for pneumococcal disease and should have immunization with in first few

post op days after splenectomy Usually attributed to blunt trauma Presentation may include CVA tenderness, microscopic or gross hematuria, bruising,

ecchymosis over the 11th and 12th ribs, hemorrhage or shock. Diagnostic testing= IVP, CT scan, angiography, cystoscopy.

Critical Care Phase ABC’c Post OP standard VS= q5min x3, q15minx3, q30min X2, q1 hour forward. Shivering is to be avoided=increase in metabolic rate and increase in oxygen demands. Physical Assessment =FULL BODY Level of Consciousness Invasive Line assessment Pain Assessment Ongoing Assessments revolve around the patient’s diagnosis and/or surgical procedure. Anticipation and prevention of untoward complications. READ PAGES 661-668 CAREFULLY

Damage Control Surgery = Staged laporaotmy Trying to avoid hypothermia, acidosis, coagulopathy Shown to improve outcomes of critically ill patients with sever intra-abdominal injuries.

ARDS Chapter 13 fully covers May occur 2 to 48 hours after traumatic injury, however sometimes up to 5 days or more

before RECOGNIZABLE clinical signs

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There are direct and indirect causes. Clinical Manifestations: hypoxemia, rising CO2 levels, tachypnea, dyspnea, pulmonary

hypertension, decreased lung compliance, new diffuse bilateral lung infiltrates. Treatment: correction of underlying cause---maximize O2 to the tissues, decrease pulmonary

congestion, prevent further lung damage, support cardiovascular system.

DVT Increased incidence of DVT= patients with obesity, age, malignancy, pregnancy, heart failure,

SCI, recent surgery, extremity fractures, pelvic fractures, history of DVT, prolonged immobilization, resp. failure, # of transfusions,central venous catheterization, vascular injury.

Clinical Manifestations= pain and tenderness, swelling fever, venous distention, palpable cord, discoloration, + Homan’s sign

Treatment= prevention, prophylaxis, early ambulation, sequential compression devices, filter placement in the inferior vena cava.

Pulmonary embolism is an often fatal complication of DVT Clinical manifestations of PE= sudden onset dyspnea, sudden onset chest pain, rapid shallow

resps, SOB, Auscultation of bronchial breath sounds, pale, dusky or cyanotic skin, Anxiety, decreased LOC, signs of hypovolemic shock (decreased BP, narrowing pulse pressure, tachycardia)

Infection Pulmonary Catheter Sepsis Sinusitis

Acute Renal Failure From systemic effects of trauma OR from actual injury to the renal system There is a reduction in renal blood flow in the trauma patient associated with shock or low

cardiac output.

Altered Nutrition

Nutritional demands are increased in the trauma patient by alterations in metabolism

Metabolism is increased by activation of the sympathetic response.

Ebb (1st 24-48 hours after injury) and Flow Phase (peaks 5-10 days after injury) Because of this increased need the patient may demonstrated: decreased body mass, increased

O2 consumption, increased CO2 production, delayed wound healing, and a weakened immune

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system Anthropometric measurements Nutrition replacement in 24 to 48 hours. Route based on individual status of patient…can be enteral, or parenteral

Multiple Organ Dysfunction Syndrome Immune, inflammatory, and hormonal responses are underlying causes. Defined as presence of altered organ function in the acutely ill There is incomplete understanding of its pathophysiology. Management focuses on prevention, early identification, elimination of sources of infection,

maint. Of tissue oxygenation and nutritional support

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