.

1

CARDINAL SIGN OF CHILDREN

Presented By:-

Deepesh Bhardwaj

Associate Professor

VITAL SIGNS (CARDINAL SIGNS)

➢ Vital signs reflect the body’s physiologic

status and provide information critical to

evaluating homeostatic balance.

➢ Includes:

➢ temperature,

➢ Pulse Rate,

➢Respiratory Rate), and

➢ Blood Pressure)

PURPOSES

✓ To obtain base line data about the

patient condition

✓ for diagnostic purpose

✓ For therapeutic purpose

3

APGAR TEST

WHY IS IT DONE?

To assess the baby’s

vital signs quickly

The score is helpful

for later evaluations

THE 5 SIGNS:

1. COLOR

a. Pale or blue = 0

b. Normal color body, but blue extremities (arms and/or legs) = 1

c. Normal color = 2 – completely pink

.

2

2. RESPIRATORY EFFORT

Respiration:

a. Not breathing = 0

b. Weak cry, irregular breathing = 1

c. Strong cry = 2

2 points for a strong cry

1 point for a slow or weak cry

0 points for no cry at all

3. HEART RATE

Heart Rate:a. Absent heartbeat = 0

b. Slow heartbeat (less than 100 beats/minute) = 1

c. Adequate heartbeat (more than 100 beats/minute) = 2

2 = good strong heartbeat

1 = slow but steady heartbeat

0 = little or no heartbeat

4. MUSCLE TONE

Muscle Tone

a. Limp, flaccid = 0

b. Some flexing or bending = 1

c. Active motion = 2

2 points for vigorous motion

1 point for small flexing

0 points for no movement

5.REFLEXES

Response to Stimulation (also called Reflex Irritability):

a. No response = 0

b. Grimace (facial expression) = 1

c. Vigorous cry or withdrawal = 2

2 points if the baby cries

1 point if the baby grimaces (facial expression)

0 points for no movement or sound

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INDICATORS 2 1 0

Activity Active,

spontaneous

Some flexion

of extremities

No movement

(flaccid, limp)

Pulse >100 bpm < 100 bpm Absent

Grimace Pulls away,

sneezes, coughs

Facial grimace

only

No response

with stimulation

Appearance Completely pink Acrocyanosis Bluish-gray or

pale all over

Respiration Good vigorous

cry

Slow, irregular

Weak cry

Absent

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Score Interpretation Nursing Interventions

7 to 10 Well baby Rarely needs resuscitation

4 to 6 At risk

INFANT NEEDS

INTENSIVE

CARE

Requires resuscitation

Suction

Dry immediately

Ventilate until stable

Careful observation

0 to 3 Sick baby

PROGNOSIS FOR

NB IS GRAVE

Intensive resuscitation

ET/ Ambu bag

Ventilate with 100% O2

CPR

Maintain body temperature

Parental support

.

3

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TEMPERATURE

Site: Axillary NOT Rectal

Duration: 3 mins

Normal Range: 36.5 – 37.6 C

Stabilizes within 8-12 hrs

Monitor q 30 mins until stable for 2

hrs then q 8 hrs

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NURSING CONSIDERATIONS

Keep dry and well-wrapped

Keep away from cold objects or

outside walls

Perform procedures in warm, padded

surface

Keep room temperature warm

Neo

natal

PULSE

Awake: 120 – 160 bpm—120 – 140 bpm

Asleep: 90-110 bpm

Crying: 180 bpm

Rhythm: irregular, immaturity of cardiac

regulatory center in the medulla

Duration: 1 full minute, not crying

Site: ApicalNeo

natal

Care

NURSING CONSIDERATIONS

Keep warm

Take HR for 1 full minute

Listen for murmurs

Palpate peripheral pulses

Assess for cyanosis

Observe for CP distress

Neo

natal

Care

RESPIRATION

Characteristics:

Nasal breathers, gentle, quiet, rapid BUT

shallow; may have short periods of apnea

(<15 secs) and irregular without

cyanosis—periodic respirations

Rate: 30-60 cpm

Duration: 1 full minute

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NURSING CONSIDERATIONS

Position on side

Suction PRN

Observe for respiratory distress

Administer oxygen via hood PRN and as

prescribed

.

4

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19

BLOOD PRESSURE

NOT routinely measured UNLESS

in distress or CHD is suspected

At birth: 80/46 mmHg*

After birth: 65/41 mmHg*

Using Doppler UTZ

03-08-2021

1

PRINCIPLES AND PRACTICES OF ASEPSIS

Presented By:-

Deepesh Bhardwaj

Associate Professor

OBJECTIVES

• Describe the principles and practice of asepsis

• Understand the role of hand hygiene in asepsis

• Understand the role of the environment in disease transmission

DEFINING ASEPSIS

Medical Asepsis Surgical Asepsis

Definition Clean Technique Sterile Technique

Emphasis Freedom from most pathogenic organisms

Freedom from all pathogenic organisms

Purpose Reduce transmission of pathogenic organisms from one patient-to -another

Prevent introduction of any organism into an open wound or sterile body cavity

MEDICAL ASEPSISMedical asepsis, also known as “clean technique” is aimed at controlling the number of microorganisms.

Medical asepsis is used for all clinical patient care activities.

Necessary components of medical asepsis include:

• Knowing what is dirty

• Knowing what is clean

• Knowing what is sterile

• How to keep the first three conditions separate

• How to remedy contamination immediately

PRINCIPLES OF MEDICAL ASEPSIS

• Perform hand hygiene

• Use of personal protective equipment and hand hygiene if contact with body fluids or potentially contaminated secretions

• Clean and disinfect shared patient equipment

• Clean and disinfect the environment

• Healthcare providers free of disease and up to date on immunizations

Surgery increases the risk of infection!

Army Medicine/CC

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2

SURGICAL ASEPSIS

Surgical asepsis, also known as “sterile technique” is aimed at removing all microorganisms.

Surgical asepsis is used for all surgical/sterile procedures.

Necessary components of surgical asepsis include:

• Knowing what is sterile

• Knowing what is not sterile

• How to keep the first two conditions separate

• How to remedy contamination immediately

PRINCIPLES OF SURGICAL ASEPSIS

• The patient should not be the source of contamination

• The operating room (OR) team should not be the source of contamination

• The surgical scrub should be done meticulously

• The OR technique of the surgeon is very important

• Recognize potential environmental contamination

HAND HYGIENEThe substance of asepsis

iStockphoto

WHAT IS HAND HYGIENE

• Handwashing with soap and water

• Antiseptic Handwash

• Alcohol-based Hand Rub

• Surgical Antisepsis

WHY IS HAND HYGIENE SO IMPORTANT?

• Hands are the most common mode of pathogen transmission

• Reduces the spread of antimicrobial resistance

• Prevents healthcare-associated infections

• Generally will not remove resident bacteria

• Will remove transient bacteria (picked up from patients, medical devices and the environment)

TRANSMISSION OF PATHOGENS ON HANDSFIVE ELEMENTS

• Germs are present on patients and surfaces near patients

• By direct and indirect contact, patient germs contaminate healthcare provider hands

• Germs survive and multiply on healthcare provider hands

• Defective hand hygiene results in hands remaining contaminated

• Healthcare providers touch/contaminate another patient or surface that will have contact with the patient.

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HAND HYGIENE COMPLIANCE IS LOWAuthor Year Sector Compliance

Preston 1981 General Wards

ICU

16%

30%

Albert 1981 ICU

ICU

41%

28%

Larson 1983 Hospital-wide 45%

Donowitz 1987 Neonatal ICU 30

Graham 1990 ICU 32

Dubbert 1990 ICU 81

Pettinger 1991 Surgical ICU 51

Larson 1992 Neonatal Unit 29

Doebbeling 1992 ICU 40

Zimakoff 1993 ICU 40

Meengs 1994 Emergency Room 32

Pittet 1999 Hospital-wide 48

<40%Pittet and Boyce. Lancet Infectious Diseases 2001

REASONS FOR NONCOMPLIANCE

• Inaccessible hand hygiene supplies

• Skin irritation

• Too busy

• Glove use

• Didn’t think about it

• Lacked knowledge

WHEN TO PERFORM HAND HYGIENE

The 5 MomentsWHO

Consensus recommendations CDC Guidelines on Hand Hygiene in healthcare, 2002

1. Before touching a patient

• Before and after touching the patient

2. Before clean / aseptic procedure

• Before donning sterile gloves for central venous catheter insertion; also for insertion of other invasive devices that do not require a surgical procedure using sterile gloves

• If moving from a contaminated body site to another body site during care of the same patient

3. After body fluid exposure risk

• After contact with body fluids or excretions, mucous membrane, non-intact skin or wound dressing

• If moving from a contaminated body site to another body site during care of the same patient

• After removing gloves

4. After touching a patient

• Before and after touching the patient• After removing gloves

5. After touching patient surroundings

• After contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient

• After removing gloves

To effectively reduce the growth

of germs on hands, handwashing

must last at least 15 seconds and

should be performed by following

all of the illustrated steps.

HOW TO HAND WASH

HOW TO HAND RUB

To effectively reduce the growth

of germs on hands, hand

rubbing must be performed by

following all of the illustrated

steps. This takes only 20–30

seconds!

http://www.who.int/gpsc/tools

/HAND_RUBBING.pdf

credit: WHO

HAND HYGIENE PROGRAM

• Involve staff in evaluation and selection of hand hygiene products

• Provide employees with hand lotions/creams compatible with soap and/or ABHRs

• Do not wear artificial nails when providing direct clinical care

• Provide hand hygiene education to staff

• Monitor staff adherence to recommended HH practices

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SUMMARY OF HAND HYGIENE

Hand hygiene must be performed exactly where you are delivering healthcare to patients (at the point-of-care).

During healthcare delivery, there are 5 moments (indications) when it is essential that you perform hand hygiene.

To clean your hands, you should prefer hand rubbing with an alcohol-based formulation, if available. Why? Because it makes hand hygiene possible right at the point-of-care, it is faster, more effective, and better tolerated.

You should wash your hands with soap and water when visibly soiled.

You must perform hand hygiene using the appropriate technique and time duration.

KNOWLEDGE CHECK

• Which of the following is not a component of asepsis

• Hand hygiene

• Environmental cleaning

• Use of isolation for individuals with multi-drug resistant organisms.

• Separation of clean, dirty and sterile items

DEFINITIONS

Spaulding Classification of Surfaces:

1.Critical – Objects which enter normally sterile tissue or the vascular system and require sterilization

2.Semi-Critical – Objects that contact mucous membranes or non-intact skin and require high-level disinfection

3.Non-Critical – Objects that contact intact skin but not mucous membranes, and require low or intermediate-level disinfection

CATEGORIES OF ENVIRONMENTAL SURFACES

Clinical Contact Surfaces

• Exam tables, counter tops, BP cuffs, thermometers

• Frequent contact with healthcare providers’ hands

• More likely contaminated

Housekeeping Surfaces

• Floors, walls, windows, side rails, over-bed table

• No direct contact with patients or devices

• Risk of disease transmission

SURVIVAL OF PATHOGENS ON SURFACES

Pathogen Survival

MRSA 7 days – 7 months

VRE 5 days – 4 months

Acinetobacter 3 days -5 months

C. difficile (spores) 5 months

Norovirus 12 – 28 days

HIV Minutes to hours

HBV 7 days

HCV 16 hours – 4 days

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SELECT, MIX, AND USE DISINFECTANTS CORRECTLY

• Right product

• Right preparation including correct dilution

• Right application method

• Right contact time

• Wear appropriate PPE (gloves, gown, mask, eye protection)

CLEANING RECOMMENDATIONS

Clean and disinfect surfaces using correct technique

•Clean to dirty

•Prevent contamination of solutions

• Don’t use dried out wipes

•Physical removal of soil (elbow grease)

•Contact time

•Correct type of cleaning materials

THANKS

03-08-2021

1

Presented By:-

Deepesh Bhardwaj

Associate Professor

1/110 children in the US are diagnosed with an

Autism Spectrum Disorder (ASD)

More common than childhood cancer, juvenile

diabetes, and pediatric AIDs combined

Prevalence increasing 10-17% annually

More common in boys

A general term used to describe a group of

developmental disorders called Pervasive

Developmental Disorders (PDD).

Wide spectrum of disorders

Mild to severe impairments

Low functioning to high functioning

Controversial terminology

Severe end of the spectrum

Extensive impairments in all areas of

development

Little or no language

Little awareness

“autism symptoms” are visibly apparent

Mild end of the spectrum

Intelligence level average or above average

Impaired social skills

Desire to communicate

“don’t know how to go about it”

• Idiopathic:

– Multiple theories:

1) Genetics

2) Heredity

3) Inflammation of CNS

4) Exposure

• Environmental: maternal rubella or cytomegalovirus

• Chemical: thalidomide or valproate during pregnancy

• NOT CAUSED BY BAD PARENTING!

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• Early Diagnoses promote positive outcome

• Symptoms noticed typically when child is 24-48 months

• No medical test

• Observed behavior

• Educational testing

• Psychological testing

• Modified Checklist of Autism in Toddlers (MCHAT)– Other screening tools available for older children

• *from birth to 36months every child should be screened for developmental milestones

• Valid for toddlers 16-30 months

• List of questions

• Answers determine need for referral to a

developmental specialist

– Developmental pediatrician

– Neurologist

– Psychiatrist

• Scoring: child requires follow up if

– Answered “No” to 2 or more critical questions or Answered

“No” to 3 questions

Please fill out the following about how your child usually is. Please try to answer every question. If the behavior is rare (e.g., you've seen it once or twice), please answer as if the child does not do it. (critical questions in red)

1. Does your child enjoy being swung, bounced on your knee, etc.? Yes No2. Does your child take an interest in other children? Yes No3. Does your child like climbing on things, such as up stairs? Yes No4. Does your child enjoy playing peek-a-boo/hide-and-seek? Yes No 5. Does your child ever pretend, for example, to talk on the phone or take care of a doll or Yes Nopretend other things? 6. Does your child ever use his/her index finger to point, to ask for something? Yes No7. Does your child ever use his/her index finger to point, to indicate interest in something? Yes No 8. Can your child play properly with small toys (e.g. cars or blocks) without just Yes Nomouthing, fiddling, or dropping them?9. Does your child ever bring objects over to you (parent) to show you something? Yes No10. Does your child look you in the eye for more than a second or two? Yes No 11. Does your child ever seem oversensitive to noise? (e.g., plugging ears) Yes No12. Does your child smile in response to your face or your smile? Yes No 13. Does your child imitate you? (e.g., you make a face-will your child imitate it?) Yes No14. Does your child respond to his/her name when you call? Yes No 15. If you point at a toy across the room, does your child look at it? Yes No16. Does your child walk? Yes No 17. Does your child look at things you are looking at? Yes No18. Does your child make unusual finger movements near his/her face? Yes No 19. Does your child try to attract your attention to his/her own activity? Yes No20. Have you ever wondered if your child is deaf? Yes No 21. Does your child understand what people say? Yes No22. Does your child sometimes stare at nothing or wander with no purpose? Yes No 23. Does your child look at your face to check your reaction when faced with Yes Nosomething unfamiliar?

Autism Spectrum Disorder (ASD)

Often called “high functioning autism”

Most diagnoses made between 3-9 years

Capable of functioning in everyday life

Individuals Diagnosed have:

Normal to advanced intelligence level

Normal to advanced verbalization skills

Severely Impaired Social Skills

• Scripted, robotic, or repetitive speech

• Inappropriate social interactions

• Conversations revolving around self

• Lack of “common sense”

• Problems with reading, math, or writing skills

• Obsessions with complex topics

• Average to below level non-verbal communicative

skills

• Verbal cognitive skills are usually above average

• Awkward movements

• Odd behaviors/mannerisms

Requires input from “healthcare team”

Doctors, teachers, psychologist, therapist, parents

Social skills training

Alternative therapies

Medications

- Antidepressants (social isolation)

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Pervasive Developmental Disorder

Similar to autism

Affects girls almost exclusively

Early growth and development

Followed by slowed growth and

development

Prevalence: 1/10,000 children in the United

States

Severity Ranges from Mild to Severe

Toe walking

Lack of eye contact

Hypotonia (weakened muscle tone)

Difficulty interacting

with others

Hand flapping

Begins with normal

development

Apraxia (loss of purposeful movements)

NO CURE

Physical therapy

Motor skills

Occupational therapy

Life skills

Speech therapy

Splints

Sensory therapy

Medical interventions

Antiepileptic

Normal development until 3 to 4 years old

Then children lose

Language skills

Motor skills

Social skills

Delay or lack of spoken language

Impairment in non-verbal behaviors

Inability to maintain conversation

Lack of play

Loss of motor, social, & communication skills

Loss of bowel/bladder control

Medication

Behavior therapy

Social skills

Speech therapy

Physical therapy

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Obtain history

Family history

When did symptoms begin?

Motor skills

Language skills

Personality

Behavior

Social skills/interactions

Decrease stimulation

Private room

Avoid extraneous auditory and visual distractions

Encourage comforting possessions (toys, blanket, etc)

which may decrease anxiety

Minimize touching child

Minimize eye contact

NO CURE

Parent education/training

Specialized educational training

Language therapy

Social skills training

Psychotherapy

Cognitive/behavioral therapy

Medications

Varies from case to case based on severity and

type of autism.

Some children improve with therapy and

medication management

Learning about autism helps improve quality of

living for child diagnosed with autism and family

members

Each child requires individualized assessment &

treatment

Not all children with ASD are the same

EDUCATION

Teach family members signs and symptoms

Help parents understand it is NOT a result of “bad

parenting

Family Support

Behavioral Modification Programs

Medications

Promote positive reinforcement

Increase social awareness

Teach verbal communication

skills

Decrease unacceptable behavior

*Providing a structured routine for the

child to follow is critical in management of

ASD*

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Treat symptoms

Hyperactivity

Depression

Anger

Aggression

Self-injurious behavior

Children with autism may not have a typical

response to medication

Monitoring Crucial

lowest dose possible to be affective

Stimulants

Ritalin

Decrease impulses and hyperactivity

Antidepressants

Valium, Ativan

SSRIs:

Zoloft, Prozac, Luvox

Treat anxiety, depression, OCD

Help decrease repetitive behaviors

Improve eye contact

Antipsychotics:

Haldol, Risperdol, Zyprexa, Geodon

Treat behavioral problems

Decrease brains use of Dopamine

Anticonvulsants:

Tegretol, Lamictal, Topamax

Monitor drug serum levelsTHANK YOU

03-08-2021

1

BED SORE

Presented BY:-

» Deepesh Bhardwaj

» Associate Professor

Definition

of Pressure Ulcer

• An area of unrelieved pressure over a defined area, usually over a bony prominence such as the sacrum

• Pressure leads to ischemia, cell death, and tissue necrosis, as capillaries are compressed and the blood flow is restricted

• Muscle is the most sensitive tissue to pressure, skin is the most resistant

How do pressure ulcers usually

present?

• 1. High pressure over bony prominence (can be a

single insult)

• 2. At muscle and bone interface, ischemia results.

• 3. Affected area with erythema, induration,

warmth, and skin is intact

• 4.Days to weeks s/p insult, EVEN WITH

PRESSURE RELIEF, the wound opens, and is a

depression with necrotic tissue

Pressure ulcers

• Associated with :

• 1. Shear forces

• 2. Impaired sensorium/sensation (SCI patients!)

• 3. Poor nutrition- serum albumin positively correlates with pressure ulcer stage, and negatively correlates with risk

• 4. Chronic illness

• 5. Elevated tissue temperature- Higher metabolic demands

• 6. Maceration

SCI patients

• Increased risk for pressure ulcer formation

• Estimated incidence 25-66%

Pathomechanics

• Shear forces- Tangential to the skin surface. Can

play a major role in the formation of sacral ulcers.

• Axial forces- Perpendicular to the skin surface.

Unrelieved axial pressure 4-6 times the systolic

pressure can cause necrosis in less than 60

minutes!

• If tissue capillary pressure is exceeded , ulcers will

form at that site.

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How much pressure is too much?

• Kosiak 1961- Studied the effects of pressure

and time on rat muscle.

• More pressure=less time for an ulcer to

form

• Found that alternating pressure of as little as

5 minute intervals led to considerably less

ulcer potential.

• Kosiak’s research led to the current practice

of turning patients every two hours.

• Why don’t we measure pressure/shear as

clinicians?

– Transducers are thick , bulky, and expensive

– Shear transducers have not been modified for

clinical use

What is a safe amount of

pressure?

• Studies by Landis et al. have led clinicians

to believe that pressures under 32 mm Hg

are generally believed safe

• This value is influenced by tissue stiffness,

tissue composition, and the patient’s body

contour

Clinical Wound Assessment

• 1. Color photography- Use ruler in picture

to give dimensions. Very useful when done

in a serial fashion. An alternative is to draw

pictures of the wound.

• 2.Location- Be specific.

• 3.Size- Be sure to include length, width, and

depth measurements, in centimeters.

Clinical Wound Assessment

• 4. Describe the type of irrigation utilized,

and the dressing type.

• 5.Drainage:

– Amount(minimal, moderate, copious)

– Color (serous, serosanguinous, prurulent)

– Odor(present, absent)

Clinical Wound Assessment

• 6. Undermining/tunneling – Present/absent

• 7. Wound character- What kind of tissue? Is

there granulation, slough?

• Stage the ulcer

• IF THERE IS ESCHAR PRESENT, YOU

CANNOT STAGE THE WOUND!

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Clinical Wound Assessments

Stage I Nonblanchable erythema not resolved in 30 minutes, epidermis intact reversible with intervention

Stage II Partial thickness loss of skin involving the epidermis, possible into dermis

Stage III Full thickness destruction through dermis into subcutaneous tissue

Stage IV Deep tissue destruction throgh subcutaneous tissue to fascia, muscle, bone

Systemic Conditions associated

with chronic wounds

SCI B/B alterations, contractures, spasticity,denervation atrophy,insensitivity

Elderly Reduced skin elasticity, altered skin microcirculation

DM Insensitivity, microangiopathy

Treatment

• Sharp debridement

• Mehanical nonselective debridement

• Enzymatic Debridement

• Autolytic debridement

Sharp debridement

• Removal of devitalized tissue/eschar via surgical means. Small wounds can be debrided at bedside, more extensive wounds can be addressed in the OR

• Most effective/quickest method of removing necrotic tissue. Debridement is done to the point where the tissue bleeds with forceps and a scalpel.

• Must have the clinical skill/judgement necessary to be able to discern the difference between vitalized and nonvital tissue.

• Cons: Can damage healthy tissue

Mechanical nonselective

debridement

• Whirlpool

• Irrigation

• Wet to Dry dressing- utilize normal saline,

place moist gauze on the wound, let dry.

– When the dressing is removed, the necrotic

tissue comes off it.

– Cons: Healthy tissue can be damaged

Wet to Dry vs. Wet to Moist

• Saline wet to dry dressings are used to

debride necrotic wounds

• Wet to moist dressings maintain a clean

moist wound bed and are removed before

they dry out.

• Wet to moist dressings have to be changed

more frequently

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Enzymatic Debridement

• Utilizes chemical agents (such as

Accuzyme) in the form of ointments which

work on the necrotic wound debris, and do

not affect the viable tissue

Autolytic debridement

• The bodies own enzymes break down dead

tissue.Wound cells secrete proteases, collagenases

that digest eschar. Hydrocolloid dressings help to

promote this type of debridement.

• Pros: Very effective in noninfected wounds- an

occlusive dressing allows wound fluid to collect

• Cons: If the wound is infected, you have just

created an abcess!

Wound dressings

• Gauze

• Transparent adhesive dressings

• Hydrocolloid dressings

• Gel dressing

• Calcium alginate dressings

Transparent adhesive dressings

• Ex. Tegaderm, Opsite

• Semipermeable, occlusive

• Stage I/II wounds without debris

• Allow gaseous exchange/water vapor transfer from the skin, prevent peri-wound maceration

• Do not use if wound is exudative or the patient is diaphoretic

Hydrocolloid dressings

• Ex. Duoderm

• Interact with wound exudate , and make a gel

• Keep wound surface moist.

• Enhances healing, protects versus secondary infection

• Help to minimize shear

– Good for shallow stage III sacral ulcers

Calcium alginate dressings

• Made from brown seaweed (ex. Sorbsan),

sterile

• Semi-occlusive, highly absorbable

• Good for treating exudative or contaminated

wounds

• Need to be frequently changed

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5

Most common pressure ulcer

sites

• Ischium 28%

• Sacrum 17-27%

• Trochanter 12-19% (Bears weight when

patient is in a sitting position)

• Other commonly affected sites include

coccyx, heel, and malleolus

Treatment

• Proper medical care

• Turn patient Q 2 hours

• Frequent dressing changes

• Proper nutrition- High protein diet indicated as a

high amount of protein is lost through the wound

• Pressure relief in wheelchair, specialty support

surfaces

• Continued wound assessment

Support surfaces

• Include overlays (water, gel , foam, air)

• Specialty beds

– Low air loss beds (Flexicare)have cushions

filled with air that keep pressures below the

capillary closing pressures

– Air fluidized beds (Clinitron) use warm air

forced through silicone beads to mimic a fluid

medium

Which support surface is best?

• No study has shown conclusively that one

surface performs better than the others!

• Must individualize your approach

• If a patient has a Stage III or IV ulcer, the

patient should be utilizing a pressure relief

product

Wound Infection

• Presentation: Foul odor, greenish drainage, dull white base (versus red granulation tissue). Can have cellulitis, with erythema, warmth, swelling, tenderness.

• Systemic bacteremia: Chills, anorexia, nausea/vomiting, fever, increased white count, mental status changes, glucose intolerance in diabetics.

• Signs of bacteremia/cellulitis- IV abx/possible debridement

Wound cultures

• Should not be routinely performed, as the cultures

will always be positive

• Exception- If antiseptic such as Betadine is used

prior to local debridement, and an abcess or other

sequestered collection is exposed

• Occasionally, cultures are taken for burn wounds

• Greater than 105 CFU’s- wound will not heal

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When are topical antibiotics

indicated for pressure ulcers?

• If a pressure ulcer does not heal after 2-4

weeks of optimal treatment, can try silver

sulfadiazine or triple antibiotic ointment x

2-3 weeks

Osteomyelitis

• Must keep in mind , especially with a Stage

IV pressure ulcer or if ulcer over a bony

prominence

• 25% of nonhealing ulcers have bone

infection

• Gold standard- Bone biopsy

• Imaging- XRay, MRI

Xray

• Reactive bone formation and periosteal

elevation =osteomyelitis

• BONE SCANS ARE A POOR STUDY TO

DETECT OSTEOMYELITIS! High false

positive rate.

03-08-2021

1

THALASSEMIA

Presented By:-

Deepesh Bhardwaj

Associate Professor

Mahatma Gandhi Nursing College

Thalassemia

Definition: Thalassemia is inherited

disorders characterized reduced or absent

amounts of hemoglobin, the oxygen-carrying

protein inside the red blood cells.

Two Basic Groups of Thalassemia

Disorder

• Alpha Thalassemia

• Beta Thalassemia: A person with this

disorder has two mutated genes

There are 3 types of Beta

Thalassemia

• Thalassemia Minor

• Thalassemia Intermediate.

• Thalassemia Major or Cooley's Anemia

Thalassemias

In the case of beta thalassemias, in

contrast to alpha -thalassemias, the

most frequently encountered molecular

abnormalities are point mutations and

short insertions or deletions limited to a

few nucleotides

Two situations have clearly to be

distinguished:

• In beta + thalassemias, the mutated

gene encodes for a small amount of

normal mRNA and, thus, a low amount

of

chain is still synthesized. The quantity of

globin chain, which is made, varies largely

from one molecular defect to another, this

chain may be structurally normal or

abnormal

• In beta 0 thalassemias , the gene is

unable to encode for any functional mRNA

and therefore there is no beta chain

synthesize

chain synthesized

Beta Thalasemia

• It is caused by a change in the gene for the beta globin component of hemoglobin

• It can cause variable anemia that can range from moderate to severe.

• Beta thalassemia trait is seen most commonly in people with the following ancestry: Mediterranean (including North African, and particularly Italian and Greek), Middle Eastern, Indian, African, Chinese, and Southeast Asian (including Vietnamese, Laotian, Thai, Singaporean, Filipino, Cambodian, Malaysian, Burmese, and Indonesian

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Symptoms of Beta Thalassemia

• It is characterize by severe anemia that

can begin months after birth

• Paleness

• Delays in growth and development

• Bone marrow expansion.

• Untreated Beta Thalassemia major can

lead to child death due to heart failure.

Alpha and Beta Thalassemias

• The thalassemias are, therefore,

considered quantitative hemoglobin

diseases.

• Because all types of thalassemia are

caused by changes in either the alpha- or

beta-globin gene. These changes cause

little or no globin to be produced.

Treatment of Beta Thalassemia

• Regular blood transfusion helps prevent

severe anemia and allows for more normal

growth and development

• There are various medications that target

the production of red blood cells (i.e.

erythropoeitin)

References

• First Known Heart Attack Associated With Beta- thalassemia Major Reported." Heart Disease Weekly February 22, 2004: 10.

• Bowden, Vicky R., Susan B. Dickey, and Cindy Smith Greenberg. Children and Their Families: The continuum of care . Philadelphia: W.B. Saunders Company, 1998.

• "Thalassemias." In Principles and Practice of Medical Genetics , Volume 2, edited by Alan E.H. Emery, MD, PhD, and David L. Rimoin, MD, PhD. New York: Churchill Livingstone, 1983.

• Thompson, M.W., R. R. McInnus, and H. F. Willard. Thompson and Thompson Genetics in Medicine , Fifth Edition. Philadelphia: W.B. Saunders Company, 1991.

• Olivieri, N. F. "The Beta Thalassemias." The New England Journal of Medicine 341 (1999): 99-109.

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Body Mechanics

Prepared By:-

Deepesh Bhardwaj

Associate Professor

• Introduction- Dangers of inactivity

❖Inactivity leads to deterioration of health. Multiple complications can occur among people with limited activity and movement. (table 23-1)

❖For example- As we get older our co-ordination, endurance and muscle strength declines. This caused limitation in mobility.

❖Inactivity leads to disuse syndrome (signs and symptoms that occurs from inactivity)

▪ What are some activities that can be done to reduce Disuse syndrome

❖ Positioning

❖ Moving the client.

▪ Nurses should use good posture when performing these activities.

See table 23-1 for dangers of inactivity and fig 23-1 for good posture

Dangers of Inactivity

▪ What is posture ?

❖Posture is the position of the body, or the way in which it is held,

that affects the person’s appearance, how the person stands, and

their ability to use the musculoskeletal system effectively.

❖Good posture distributes gravity through the center of the body

over a wide base for clients and staff.

❖Poor Posture causes muscle spasms ( which are sudden, forceful,

and involuntary muscle contraction). This occurs because

muscles are strained and are forced to work harder

Maintaining Good Posture

Maintaining Good Posture

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Standing Posture ▪ Correct Standing Position

❖Another way to maintain good posture is standing.

❖Most effective, when feet are parallel, with weight equally distributed on both feet to provide a broad base of support. bend knees slightly, chest up and slightly forward, shoulders ,even and centered above hip, hold head erect, face forward and chin slightly tucked

Sitting Posture

• Correct sitting posture

➢ Buttocks and thighs base of support

➢ Both feet rest on floor

➢ Knees bent and clear of chair edge

• Good lying-down posture - horizontal

❖ Head, neck centered between shoulders

❖ Shoulders level; arms, hips, knees slightly flexed

❖ Trunk straight; hips level; legs parallel; feet at right

angles to legs

Lying-Down Posture

Body Mechanics

• Proper body mechanics (the effective use of the

musculoskeletal system) will

❖ Increase muscle effectiveness

❖ Reduce fatigue

❖ Avoids repetitive strain injuries (disorders that

results from cumulative trauma to musculoskeletal

structures).

Nursing Guidelines

• Using Good body Mechanics (nursing guidelines)

➢Use the longest and strongest muscles of arms and legs

➢When lifting a heavy load, center is over feet.

➢Hold objects close to the body

➢Bend the knees

➢Contract the abdominal muscles and make a long midriff

➢Push, pull or roll objects whenever possible rather than lifting them.

➢Use body weight as a lever to assist with pushing or pulling an object

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Ergonomics

• Definition: special field of engineering science devoted to

the promotion of comfort, performance of health in the

workplace. Helps in the design of health in the work

environment .

❖ Example: using assistive devices to lift or transport

heavy items or clients; using alternative equipment

for task that require repetitive motions e.g. headsets

or automatic staples.

Ergonomics Examples

• Positioning equipment – to avoid reaching and twisting at the hip

• Promoting stability by keeping feet apart

• Use strong muscles to improve balance by bending knees and keeping the back straight

• Avoid twisting and stretching muscles

• Rest between periods of exertion.

❖Some nurses are prone to injury in the work during lifting patients, twisting while lifting, reaching and lifting with loads far from the body

Positioning Clients

• General principles for positioning

• Changing inactive clients position to relieve pressure &

improve Functional mobility (alignment that maintains

the potential for movement & ambulation)

❖Change the inactive client’s position at least every 2 hours

❖Enlist the assistance of at least one other caregiver

❖Remove pillows and positioning devices

❖Unfasten Drainage from the bed linen.

❖Use Low friction fabric or gel filled plastic sheet, repositioning sling to slide/ do not drag the client

❖Turn client as a complete unit ( avoid injury to spine)

❖Place the client in good alignment with joints slightly flexed

❖Replace pillows and positioning devices

❖Support limbs in a functional position

❖Use elevation to relieve swelling

❖Provide skin care after repositioning

• Common positions for bed ridden clients, supine,

lateral oblique, prone, sim’s, and Fowler’s

❖Supine position: client lies on back.

❖ Concerns-prolonged pressure & skin breakdown.

Foot drop: permanent dysfunctional position caused

by shortening of the calf muscles and lengthening of

the opposing muscles on the anterior leg.

Foot Drop

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• Lateral position- Side lying position

• Lateral Oblique- variation of side lying position

• Prone position-client lies on abdomen

provides drainage from bronchioles

Alternate position for client’s with ulcers

A challenge for nursing care.

• Sim’s position- a semi prone position. Used for rectal and vaginal procedures.

• Fowler’s position- semi-sitting position. Lowers abdominal organs from diaphragm , making breathing easier. Three types.

Common Positions

• Positioning devices

– Adjustable bed

– Mattress

– Bed board (rigid structure placed under a mattress)

– Pillows

– Roller sheets

– Turning and moving clients

– Assistive devices and additional

caregivers are needed when turning or

moving a client who cannot change

from one position to another

independently

Trochanter Rolls -Prevents legs from turning outwards Hand Rolls- prevents contractures, helps clients

functional mobility to grasp objects

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Foot Boards, Boots, and Foot SplintsTrapeze- triangular, over the bed, helps client to

lift the body and move

Protective/Pressure-Relieving Devices

• Side rails- aids in changing position

• Mattress overlays- reduces pressure

– Foam and gel mattresses-

– Static air mattress-distributes pressure

– Alternating air mattress-relieves pressure

– Water mattress –equalizes pressure

Protective devices

• Cradle: metal frame secured to or placed on top of the mattress to protect feet and lower legs from bed linens

• Specialty beds

– Low air loss

– Air fluidized

– Oscillating support

– Circular bed

Transferring Clients

• Transfers –moving client from one place to the next,

from bed to chair/toilet or stretcher/back to bed.

• Examples of transferring aids

– Transfer handle- active /independent

– Transfer belt – gripping/support for client

– Transfer boards – bed to stretcher

– Mechanical lift- raise/transfer, obese/helpless

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• Nursing diagnoses for inactive clients

– Impaired physical mobility

– Risk for injury

– Risk for disuse syndrome

– Impaired bed mobility

Nursing Implications

THANKS YOU

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1

ESSENTIAL NEWBORN CARE

PRESENTED BY:

DEEPESH BHARDWAJ, M.Sc (N),

ASST. PROF.,

DEPT. OF PAEDIATRICS,

MAHATMA GANDHI NURSING COLLEGE,

JAIPUR.

INTRODUCTION:

Essential care of the normal healthy

neonates can be best provided by the mothers

under supervision of nursing personnel or

basic/ primary health care providers. About

80% of the newborn babies should be kept

with their mothers rather than in a separate

nursery.

HEALTHY NEWBORN

A healthy infant born at term b/w 37-40

wks should have average birth wt, cries

immediately following birth, establishes

independent rhythmic respiration & quickly

adapts to the changed environment.

IMMEDIATE BASIC CARE

❖ Establishment of open airway & circulation

❖Maintenance of temperature

❖ Identification of newborn

❖ Vitamin K injection

❖ Initiation of breastfeeding.

Establishment of open airway:

(Majority of babies cry at birth & take

spontaneous Respiration)

✓ When the baby is delivered birth attendant

immediately suction the secretions, wipe

mucus from face and mouth and nose.

✓Suction the mouth and nose by using bulb

syringe

Maintenance of temperature:-

Immediately dry the neonate under a radiant

warmer

❖ Skin to skin contact with the mother.

❖ Keep neonates head covered.

❖ Rooming in (The baby should not be

separated from the mother)

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APGAR SCORING

CRITERIA 0 1 2

Respiration Absent Slow, irregular Good, crying

Heart rate Absent Slow (Below 100) More than 100

Muscle tone Flaccid Some flexion of extremities

Active body movements

Reflex response No response Grimace Cry

Skin color Blue, pale Body pink, extremities blue

Completely pink

TOTAL SCORE = 10

➢ No depression: 7-10

➢Mild depression: 4-6

➢Severe depression: 0-3

Newborn Identification:

Newborn Identification Before a baby

leaves the delivery area, identification

bracelets with identical numbers are placed

on the baby and mother. Babies often have

two, on the wrist and ankle.

• Vitamin K:

Vitamin K Prevent neonatal hemorrhage

during first few days of life

✓ Term infants (1mg) - IM

✓Preterm infants (0.5mg) – IM

• Alternative Route:

✓ Oral Dose: 2mg orally at birth;

✓ Repeat dose (2mg) at 3-5 days and at 4-6

weeks of age.

Initiation of breastfeeding:

Babies can be breast-fed as soon as the

airway is cleared and they are breathing

normally.

DAILY ROUTINE CARE OF NEONATES

The majority of complication of the normal

newborn may occur during first 24 hours

or within 7 days. So close observation &

daily essential routine care is important for

health & survival of the newborn baby.

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The daily routine care of the neonates are

as follows:

✓ Warmth

✓ Breastfeeding

✓ Skin care & baby bath

✓ Care of umbilical cord

✓ Care of the eyes

✓ Clothing of the baby

WARMTH

Warmth is provided by keeping the baby dry

& wrapping the baby with adequate clothing

in two layers, ensuring head & extremities

are well covered. Baby should kept by the

side of the Mother.

BREAST FEEDING

Breastfeeding The baby should be put to the

mother’s breast within half an hour of birth or

as soon as possible the mother has

recovered from the labour.

Skin care & baby bath:

The skin should be cleaned off blood,

mucus & meconium by gentle wiping

before he/she is presented to the mother.

Baby bath can be given at the hospital or

home by using warm water in a warm

room gently & quickly.

CARE OF THE UMBILICAL CORD

✓ Keep the cord stump clean and dry.

✓ Topical application of antiseptics is usually

not necessary unless the baby is living in a

highly contaminated area.

✓Observe any bleeding

or discharge

Care of the eyes. :

Eyes should be clean at birth using sterile

cotton swabs soaked in sterile water or

normal saline. Separate swabs for each

eye.

Clothing of the baby:

✓ The baby should be dressed with loose,

soft & cotton cloths. The frock should be

open on the front or back for easy

wearing.

✓ Large button, synthetic frock and plastic

or nylon napkin should be avoided.

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Observation:

The baby should be kept in continuous

observation twice daily for detection of any

abnormalities.

• Anthropometric measurement:

✓Measure weight

✓length

✓Head circumference

✓Chest circumference

WEIGHT:

✓The normal weight at birth 2.5-3.5 kg

✓The average daily wt gain for healthy term

babies is about 30gm/day in the first month

of life

LENGTH: (from top of head to the heel with

the leg fully extended)

✓Average range: 18-22 inches (46-56 cm)

Head circumference:

Head circumference average range: 33 to 35

cm (13-14 inches) Normally, 2 cm larger than

chest circumference Place tape measure above

eyebrows and stretch around fullest part of

occipital at posterior fontanel.

Chest circumference (at the nipple line):

Average range: 30-33 cm (12-13 inches) Normally, 2

cm smaller than head circumference Stretch tape

measure over nipple line.

Immunization:

Newborn should be immunized with BCG vaccine &

‘0’ dose of ‘OPV’. Hepatitis ‘B’ vaccine can be

administered at birth as first dose.

Follow up & Advice:

Each infant should be followed up, at least

once every month for first 3 months &

subsequently 3 month interval till one year of

age.

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HARMFUL TRADITIONAL PRACTICES

FOR THE CARE OF NEONATES

✓ use of unclean substance such as cow dung, mud on

umbilical card,

✓ immediate bathing,

✓ use of prelacteal feeds,

✓ application of kajal in the newborn eyes,

✓ instillation of oil drops into ears & nostrils,

✓during bathing the baby use of unhygienic

herbal water,

✓ introduction of artificial feeding with

diluted milk,

✓ giving opium & brandy to neonates

✓ use of readymade expensive formula

foods.

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CODE OF ETHICS &PROFESSIONAL CONDUCT FOR NURSES

Prepared By:-Deepesh Bhardwaj

Associate Professor

MGNC jaipur

•THE ICN CODE OF ETHICS FOR NURSES:-

•An international code of ethics for nurses was first adopted by the International Council of Nurses (ICN) in 1953.

• It has been revised and reaffirmed at various times since, most recently with this review and revision completed in 2005.

•INTRODUCTION:-

• It is no possible in real life to separate “ethical” behavior from all other behavior and practice.

• - Almost everything we do can be judged as a moral act by some group ofpersons. It is because ethical behavior is important but not easily understood.

•Nurses have four fundamental responsibilities: to promote health, to prevent illness, to restore health and to alleviate suffering.

• The need for nursing is universal. Inherent in nursing is respect for human rights, including cultural rights, the right to life andchoice, to dignity and to be treated with respect.

- Nursing care is respectful of and unrestricted by considerations of age, colour, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status.

- Nurses render health services to the individual, the family and the community and co-ordinate their services with those of related groups.

•FOUNDATION OF THE CODE:-

Ethical nursing practice involves core ethical responsibilities that nurses are expected to uphold.

• Nurses are accountable for these ethical responsibilities in their professional relationshipwith individuals, families, group, population, communities and colleagues.

•Nursing ethics is concerned with how broad societal issues affect health and well being.

• This means that nurse endeavor to maintain awareness of aspect of social justice that affect health and well being and to advocate for change.

•The code is organized into two parts:-Part I: Nursing Values and Ethical Responsibilities:-

- It describes the core responsibilities central to ethical nursing practice.

- These ethical responsibilities are articulated throughseven primary values and accompanying responsibilitystatement, which are grounded in nursing professionalrelationship with individuals, families, groups, population and communities as well as with students, colleagues and other health care professionals.

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•The seven primary values are:- Providing safe, compassionate, competent and ethical care.- Promoting health and well-being.- Promoting and respecting informed decision-making.- Preserving dignity.- Maintaining privacy and confidentiality.- Promoting justice.- Being accountable

•Part II: Ethical Endeavours• Ethical nursing practice involves endeavouring to address

broad aspect of social justice that is associated with health and wellbeing.- Values are related and overlapping.

• It is important to work towards keeping in mind all the values in the code at all times for all people in order to uphold the dignity of all.

• In Health care practice, values may be in conflict.

• Such values conflicts need to be considered carefully in relation to the practice situation.

• When such conflict occurs, or when nurses need to think through an ethical situation, many find it helpful to use ethics model for guidance in ethical reflection, questioning and decision-making.

•THE ICN CODE:

•The ICN Code of Ethics for Nurses has four principal elements that outline the standards of ethical conduct.- Ethical nursing practice involves core ethicalresponsibilities that nurses are expected touphold.

- Nurses are accountable for these ethicalresponsibilities in their professional relationshipwith individuals, families, group, population,communities and colleagues.

•NURSES AND PEOPLE-

• The nurse’s primary professional responsibility is to people requiring nursing care.

• In providing care, the nurse promotes an environment in which the human rights, values, customs and spiritual beliefs of the individual, family and community are respected.

• The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment.

•The nurse holds in confidence personal information and uses judgment in sharing this information.

•The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.

•The nurse also shares responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction.

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• NURSES AND PRACTICE

• The nurse carries personal responsibility and accountabilityfor nursing practice, and for maintaining competence bycontinual learning.

• The nurse maintains a standard of personal health such thatthe ability to provide care is not compromised.

• The nurse uses judgment regarding individual competencewhen accepting and delegating responsibility.

• The nurse at all times maintains standards of personalconduct which reflect well on the profession and enhancepublic confidence.

• The nurse, in providing care, ensures that use of technologyand scientific advances are compatible with the safety, dignityand rights of people.

•NURSES AND THE PROFESSION:-

• The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education.

•The nurse is active in developing a core of research based professional knowledge.

• The nurse, acting through the professionalorganization, participates in creating and maintaining safe, equitable social and economic working conditions in nursing.

•NURSES AND CO-WORKERS

• The nurse sustains a co-operativerelationship with co-workers in nursing andother fields.

• The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a coworker or any other person.

•Elements of the code-1:NURSES & THE PEOPLE

Practitioners & managers Educators & Researchers National Nurses Associations

Provide care that respects human rights and is sensitiveto the values, customs and beliefs of all people.

In curriculum includereferences to human rights, equity, justice, solidarity as the basis for access to care.

Develop positionstatements and guidelines that support humanrights and ethicalstandards.

Provide continuingeducation in ethicalissues.

Provide teaching andlearning opportunitiesfor ethical issues anddecision making.

Lobby for involvementof nurses in ethics reviewcommittees.

Provide sufficientinformation to permit informed consent and theright to choose or refuse treatment.

Provideteaching/learningopportunitiesrelated to informedconsent.

Provide guidelines,position statementsand continuingeducation related toinformed consent.

PRACTITIONERS ANDMANAGERS

EDUCATORS ANDRESEARCHERS

NATIONAL NURSES’ASSOCIATIONS

Use recording andinformationmanagementsystems that ensureconfidentiality.

Introduce intocurriculum conceptsof privacy and confidentiality

Incorporate issuesof confidentialityand privacy intoa national code ofethics for nurses.

Develop andmonitor environmentalsafety in theworkplace.

Sensitize students tothe importance ofsocial action incurrent concerns.

Advocate for safeand healthyenvironment.

• Element of the Code 2: NURSES AND PRACTICE

Practitioners andManagers

Educators andResearchers

National Nurses’Associations

Establish standardsof care and a work setting thatpromotes safety and qualitycare.

Provide teaching/learningopportunities that foster life long learning and competence for practice.

Provide access to continuingeducation, through journals,conferences, distance education, etc

Establish systems forprofessional appraisal,continuing education andsystematic renewal of licensure to practice.

Conduct and disseminateResearch that shows linksbetween continual learning and competence to practice.

Lobby to ensure continuingeducation opportunities andquality care standards.

Monitor and promote thepersonal health of nursing staff in relation to their competence for practice.

Promote the importance ofpersonal health and illustrate its relation to other values.

Promote healthy lifestyles fornursing professionals Lobbyfor healthy work places andservices for nurses.

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•Element of the Code 3: NURSES AND THE PROFESSION

Practitioners andManagers

Educators andResearchers

National Nurses’Association

Set standards for nursing practice,Research, education andmanagement .

Provide teaching/learningopportunities in setting standardsfor nursing practice, research,education andmanagement.

Collaborate with others to setstandards for nursing education,practice, researchand management

Foster workplace support of theConduct, dissemination andutilization of research relatedto nursing and health

Conduct, disseminateand utilize research toadvance the nursing profession.

Develop position Statements,guidelines and standards related tonursing research.

Promote participation in nationalnurses’ associations so as tocreate favorable socio-economicconditions for nurses

Sensitize learners to the importanceof professional nursingassociations

Lobby for fair social andeconomic working conditions in nursing. Develop positionstatements and guidelines inworkplace issues.

• Element of the Code 4: NURSES AND CO-WORKERS

Practitioners andManagers

Educators andResearchers

National Nurses’Associations

Create awareness of specific and Overlapping functions and the potential for interdisciplinarytensions.

Develop understandingof the roles of other workers.

Stimulateco-operation withother relateddisciplines.

Develop workplace systems that support common professionalethical values and behavior.

Communicate nursing ethics to other professions.

Develop awareness of ethicalissues of other professions.

Develop mechanisms tosafeguard the individual, family or community when their care is endangered by health care personnel .

Instill in learners the need tosafeguard the individual, family or community when care is endangered by health care personnel.

Provide guidelines, positionstatements and discussionFor a related to safeguardingpeople when their care isendangered by health carePersonnel .

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1

BREAST FEEDING

Presented By:-

Deepesh Bhardwaj

Associate Professor

Mahatma Gandhi Nursing College

▪ Giving an infant only breastmilk, with the exception of drops or syrups consisting of vitamins, mineral supplements, or drugs

▪ No food or drink other than breastmilk—not evenwater

Benefits to the Baby

• Complete food for the first six months

• Perfect nutrition

• Higher IQ

• Emotional bonding

• Prevents infections

• Prevents chronic diseases

• Easily digested

Benefits to the Mother

• Reduces post delivery bleeding and anemia

• Helps delay next pregnancy

• Protective effect against breast and ovarian cancer

• Helps to loose weight• Emotional bonding• Needs no preparation

• Lack of family support

• Lack of support by health professionals

• Commercial influence

• Feeling of not enough milk among women

Important Do’s• Initiate breastfeeding as early as possible within one

hour of birth.

• Do not give the baby any prelacteal feeds

• No bottles, artificial teats or pacifier

• Breastfeeding on demand at least 8-10 times in a day

and at night a

• Breastfeed in a correct position

• Build mother’s confidence to sustain good milk

supply and alleviate feeling of not enough milk.

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• Initiate Breastfeeding Within One Hour of Birth

• No Bottles, Artificial Teats or Pacifiers for Breastfeeding Infants

Breastfeed on demand

• 8-10 times or more in 24 hours

• Breastfeed at night

• No restrictions on length of breastfeeds

• No restrictions on frequency of breastfeeds

Signs of Correct Attachment

• Mouth wide open

• Lower lip is turned outside

• Chin touching the breast

• Black part of the breast not

visible below the lower lip

• Large black portion of

breast and nipple including

milk collecting ducts are

inside baby’s mouth

• Tongue under the teat

Incorrect Sucking Position

• Mouth is not wide open

• Chin is away from the breast

• Baby is sucking only nipple

• Most black portion of the breast is outside the baby’s mouth

• Tongue away from the teat

Causes of Incorrect Attachment

• Use of feeding bottles. Leads to nipple confusion

• Inexperienced mother

• Functional difficulty with the mother or the baby

• Lack of skilled support

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• More prolactin

secreted at night

• Secreted after feed

to produce next feed

• Suppresses

ovulation

The Prolactin reflex

Baby

sucking

Sensory Impulses

from nippleProlactin

in blood

Breastmilk ProductionThe Oxytocin reflex

Breastmilk Transfer

• Works before or during

feed to make milk flow

• Makes uterus contractBaby

sucking

Sensory Impulses

from nippleOxytocin

in blood

How does the mother’s

confidence play part

Breastmilk Transfer

Thinks lovingly

of baby

CONFIDENCE

Sound of baby

Sight of baby

Pain

Worry

Stress

Doubt

Being Successful-

• Initiate breastfeeding as early as possible within one hour of birth.

• Do not give the baby any prelacteal feeds

• No bottles, artificial teats or pacifier

• Breastfeeding on demand at least 8-10 times in a day and at night a

• Breastfeed in a correct position

• Build mother’s confidence to sustain good milk supply and alleviate feeling of not enough milk.

THANK YOU

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1

Hospitalization of Sick child

Presented By:-

Deepesh Bhardwaj

Associate Professor

MGNC Jaipur

INTRODUCTION➢ The Sick Child Is Different From Sick Adult.

➢ The Differences Of Illness In Children And Adults Are Based On Anatomic , Physiologic And Psychologic Differences Between The Immature Child And The Mature Adult. Often Illness And Hospitalization Are The First Crises , Children Must Face .

➢ During early years , children's are particularly vulnerable to the stressors because stress represents a change from the usual state of health and environmental routine

ADMISSION➢ Introduce primary nurse to child and family .

➢ Orient child and family to inpatient facilities , to assigned room and unit .

➢ A pediatric unit should be happy and attractive place with cheerful home like surroundings .

➢ It should have colorful walls with suitable pictures .

➢ Furniture should be of attractive and colorful without any poisonous paints , any projections and sharp edges .

➢ Floor should not be slippery and safety measures to be maintained.

➢ A pediatric unit should have facilities of separate areas for different types of ill child , treatment room , examination room , play room ,dinning room and pantry , waiting room for visitors and parents , consultation room , teaching room for visitors.

➢ A pediatric unit should have facilities of separate areas for different types of ill child , treatment room , examination room, play room dinning room and pantry , waiting room for visitors and parents , consultation room, teaching room for visitors, store room , bathroom for children's and adults, nurses station,doctors room etc.

➢ The pediatric unit must meet the needs of children's and their parents.

➢ The physical environment of pediatric unit should be pleasing by maintenance of cleanliness and orderliness of furniture and equipment

There should have good lighting , plenty of fresh air and good ventilation without any droughts.

There should have comfortable temperature (about 22 -25c) and humidity(about 65%) should be maintained.

The spacing between two beds should be maintained with 6-8 feet with adequate cleaning facilities.

The unit should be free from fly , mosquitoes , bed bugs , cats and dogs

There should have facilities for isolation of infectious patients ; disinfection of articles and other methods of cross infections.

Provision of safety measures for prevention of accidents in the paediatric unit.

There should be recreation facilities like toys , music and television to reduce fear and anxiety of the children

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CONCEPTS TO MINIMIZE EMOTIONAL TRAUMA IN CHILDREN'S AND PARENTS

Family integrity and child's relationship should be maintained.

The sick child should be supported and guided to learn to handle new experiences and feelings by family participation to provide love and security during illness and hospital stay.

Needs of each child are different , assessment of these needs as well as those of family members forms the basis of nursing interventions.

The paediatric nurse seeks to promote , maintain and restore health in both children and their parents by health counselling and teaching about the needs

Hospitalized child should be cared by the professional nurses following scientific principles of disease process and nursing process with appropriate therapeutic and nursing process.

Family participation for planning , implementation and evaluating plan of care is essential for optimal outcome by continuity of care.

With in safe environment , the sick child needs expert physical care , emotional support, expression of feelings ( through play) and continuation of school education , to promote continued growth , both in acute and chronic illness

Parents should have trusting relationship with nurses and health team members and permission for expression of feelings and emotions in the hospital environment.

Family members and their child , who are under great stress , when a child is terminally ill or dying must be supported emotionally so the child can die with dignity and with a feeling of being loved.

Hospitalization is the break in the unity of the family , so the emotional effects should be considered first , because it is often mistakenly accorded less importance than the physical care given to the sick child

CHILDS REACTION TO HOSPITALISATION AND ILLNESS

Reactions of neonate

Hospitalization and prolonged illness in neonatal period interrupts in the early stages of development of a healthy mother-child relationship and family integration.

Impairment of bonding and trusting relationship ,inability of the parents to love and care for the baby and inability of the baby to respond to parents and family members.

REACTION OF INFANTS • Infants reaction are mainly separation anxiety and disturbance of

development of basic trust , when the infant is separated from mother and when illness and hospitalisation .

• Emotional withdrawal and depression are found in the infants of 4 to 8 months of age , interference of growth and delayed developments also found.

• Older infants 8 to 12 months of age may have limited tolerance due to separation anxiety which is found as fear of strangers , excessive crying , clinging and overdependence on mother

• The major stress from middle infancy throughout the preschool years , especially for children ages 6 to 30 months , is separation anxiety

• The major stress from middle infancy throughout the preschool years , especially for children ages 6 to 30 months , is separation anxiety .

• STAGE OF PROTEST ; Children's react aggressively to the separation from the parent. They cry and scream for their parents ,refuse the attention of anyone else and are inconsolable in their grief .

• STAGE OF DESPAIR ; The crying stops , and depression is evident , the child is less active , is uninterested in play or food , and withdraws from others.

• STAGE OF DETACHMENT OR DENIAL ; Superficially , it appears that the child has finally adjusted to the loss. The child become more interested in the surroundings , plays with others and seems to form new relationships

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REACTIONS OF TODDLERS

The toddlers PROTESTS by frequent crying , shaking crib, rejecting nurses attention , urgent desire to find mother and showing signs of distrust with anger and tears ,especially when with mothers.

In DESPAIR , the toddler becomes hopeless , apathetic , anorectic , listless ,looks sad , cry continuously or intermittently and use comfort measures like thumb sucking , fingering lip and tightly clutching a toy.

In DENIAL ,the child reacts by accepting care without protest and represses all feelings. The child does not cry in the absence of mothers and may seem more attached to nurses.

The toddler may react by REGRESSION in an at

The toddler may react by REGRESSION in an attempt to regain control of a stressful situation.

They are found to stop using newly acquired skills and may return to the behavior of an infant during

illness and hospitalization

REACTIONS OF PRESCHOOL CHILD

• The preschool children adopt various mental mechanisms (defence mechanisms) to adjust with the stressful experiences of hospitalization and prolonged illness.

• They react by exhibiting regression , repression , projection , replacement , identification , aggression , denial , withdrawal and fantasy .

• The stage of PROTEST in preschool children is usually less aggressive and direct

REACTIONS OF SCHOOL AGED CHILDREN’S

• The school age children are concerned with fear, worry, mutilation ,fantasies, modesty, and privacy.

• They react with defense mechanisms like regression, separation anxiety, negativism, depression , phobia, unrealistic fear, suppression or denial of symptoms and conscious attempts of mature behavior

REACTIONS OF ADOLESCENTS

• Adolescents are concerned with lack of privacy , separation from peers or family and school , interference with body image or independence or self concept and sexuality.

• They react with anxiety related to loss of control and insecurity in strange environment .

• They may show anger and demanding or un co-operative behavior or increased dependency on mothers and staff.

• They may adopt mental mechanism like intellectualization about disease , rejection of treatment , depression ,denial or withdrawal

EFFECTS OF HOSPITALISATION ON THE FAMILY

• Break in the unity of family.

• Separation from the children.

• Feeling of inadequacy as others care for their children .

• They feel anxiety, anger, fear, disappointment , self blame, and possible guilt feeling due to lack of confidence and competence for caring the child in illness and wellness.

• Parental anxiety related to ;

• Strange environment in the hospital.

• Unknown events and outcome

• Spread of infections of other members from the family

• Society will look upon the illness as a reflection of something wrong with the parents.

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ROLE OF NURSE TO HELP TO COPE WITH HOSPITALISATION OF CHILDREN

• . The nurse should earn sufficient confidence to develop positive relationship with the children and their parents .

• Nurse should have patience, tenderness and emotional strength in times of stress.

• Provide family centred care with different approach to specific age group.

• IN NEONATE: Rooming in and sensory motor stimulation

• IN INFANTS : Encourage mother to balance her responsibilities and minimize separation , mother can be allowed during procedure , providing toys to relieve tension.

• IN TODDLERS : Rooming in , unlimited visiting hours to express child's feelings, no punishment to the child, home routines can be continued , allow play , encourage independence , encourage family interaction.

• IN PRESCHOOLER: Provide parental participation in care , plan to shorten the hospital stay, careful reparation for all procedures by privacy and explanation, encourage the child to participate in the selfcare and hygiene, remove fear , reassure the child

• IN SCHOOLCHILDREN :

• Help the parent to prepare child for elective hospitalization , provide privacy , thorough nursing history should be obtained for plan of care , explain the procedures and its purpose , encourage play , self care and continue schoolwork, ensure parents to cope with their own anxieties, introduce to other parents in the same unit and consistent visiting pattern.

• IN ADOLESCENTS: Prepare the parents for planned hospital admission , available hospital facilities should be explained soon after admission, respect the personal preference on selfcare and food habit , explain all procedure, provide opportunities for recreation , peer relationships, interaction with other adolescent patients and expression of feelings

STRATEGIES FOR ADAPTATION IN NURSING CARE

Welcome the child and parents during each nursing intervention.

Call by name and touch the gently with love.

Explain the intervention in simple sentence according to the level of understanding .

Ask for cooperation and its benefits. Encourage to express the feelings.

Demonstrate the interest and empathy to the child and family members.

Explain and reason out any unpleasant experience of the past which will reduce anxiety level and help to obtain co-operation.

Allow parents or significant other during any treatment or nursing procedures

Maintain privacy , minimize ,exposure and gentle handling of the child during nursing care

Provide physical comfort by appropriate positioning ,warmth, bladder evacuation etc. before and during the interventions.

Take opinion of the parents and the child during any decision making regarding the treatment plan, diagnostic procedures and nursing intervention.

Maintain eyelevel contact during conversation.

Diverts the child's attention by toys or telling story.

Protect the child from physical injury and infections.

Assure about confidentiality of the information whenever required especially for older children.

Praise the child for cooperation, never threat or blame the child for non cooperation

Thank YOU

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Deepesh Bhardwaj

Associate Professor

✓10 million children/Year die in developing

countries due to acute respiratory infections,

diarrhoea, measles, malaria, malnutrition

✓ 1990-WHO+UNICEF +other agencies- (IMCI)

✓ India adopted as (IMNCI).

INTRODUCTION

STRUCTURE OF IMNCI

IMNCI caters to two groups of children

0-2 Month 2 Month to 5 Year

Reduce

Mortality IMPROVE GROWTH AND

DEVELOPMENT DURING THE

FIRST 5 YEARS OF A CHILD'S

LIFE

OBJECTIVES

Reduce

Illness

Health worker component

Improvement in Family And

Community

health care practices.

COMPONENTS OF IMNCI

Improvements in the case-management skills

SKILLED CASE-MANAGEMENT

TRAININGGUIDELINES

A. HEALTH WORKER COMPONENT

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1. All sick children under 5 years of age must be

examined for conditions which indicate immediate

referral or hospitalization.

2.Children must be routinely assessed for major

symptoms, nutritional and immunization status, feeding

problems and other potential problems.

3. Only a limited number of carefully selected clinical

signs, are used based on evidence of their sensitivity and

specificity to detect disease.

4. -Based on the presence of selected clinical signs, the

child is placed in a ‘classifications’.

-Classifications are not specific diagnosis but

categories that are used to determine the treatment.

Referral

Health

Facility

Management

At Home

5. IMNCI guidelines address most common

but not

all paediatric problems.

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6.A limited number of essential drugs are used. 7.Care takers are actively involved in the

treatment of children.

8.Counselling of caretakers about home care

including feeding, fluids and when to return to

health facility

IMNCI guidelines recommend standardized case

management procedures

That based on two age categories: -

1.Upto 2 months and

2.2 months to 5 years

IMNCI PACKAGE

Care of Newborns and Young Infants

(infants under 2 months)

1.Keeping the child warm.

2.Initiation of breastfeeding immediately after birth and

counseling for exclusive breastfeeding and non-use of

pre lacteal feeds.

3.Cord, skin and eye care.

4.Recognition of illnessin newborn and

management and/or referral).

5.Immunization

6.Home visits in the postnatal period.

Care of Infants (2 months to 5 years)

1.Management of diarrhea, acute respiratory infections,

malaria, measles, acute ear infection, malnutrition and

anemia.

2.Recognition of illness and at risk conditions and

management/referral)

3.Prevention and management of Iron and Vitamin A

deficiency.

4.Counseling on feeding for all children below 2 years

5.Counseling on feeding for malnourished children

between 2 to 5 years.

6.Immunization

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IMNCI CASE MANAGEMENT

PROCESS

Steps of case management process are the following:

1.Asses the young infant/ child.

2.Classify the illness.

3.Identify the treatment.

4.Treat the young infant/child.

5.Counsel the mother.

6.Provide follow up care.

< 2 Months of Age

2 months to 5 Yr ADVANTAGES OF INTEGRATED

APPROACH

•Speeds up the urgent treatment and treatment seeking

practices.

•Prompt recognition of serious condition, hence prompt

referral.

•Involves parents in effective care of baby at home.

•Partial Success of Individual disease control

programme.

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Presented By

Deepesh Bhardwaj

Associate Professor

SCIENTIFIC KNOWLEDGE BASE

ENTRY AND MULTIPLICATION OF

ORGANISM RESULTS IN DISEASE

COLONIZATION OCCURS WHEN A

MICROORGANISM INVADES THE

HOST BUT DOES NOT CAUSE

INFECTION (INJURY TO CELLS)

PATIENT SAFETY ISSUE

CHAIN OF INFECTION

➢ Infectious agent or pathogen

➢ Reservoir

➢ Portal of exit

➢ Mode of transmission

➢ Portal of entry

➢ Susceptible host

Infectious Agent/Pathogen

➢ Microorganisms (bacteria, viruses,

fungi, protozoa

➢ Normal flora

➢ Colonization

➢ Virulence

➢ Susceptibility

➢ Review Potter & Perry Table 34-1 (pg.

643) Common Pathogens

Reservior

➢ Animate sources (humans, animals,

insects)

➢ Inanimate sources (soil, water, food,

medical equipment)

➢ Pathogens need a proper environment

to survive (food, oxygen, water,

temperature, pH, light)

➢ Carriers

➢ Toxins: (Exotoxins, endotoxins)

Portal of Exit/Entry

Skin and Mucous Membranes

Respiratory Tract

Urinary Tract

Gastrointestinal tract

Reproductive Tract

Blood

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Modes of Transmission

Contact (Direct & Indirect)

Droplet

Airborne

Vehicles

Vectors

Susceptible Host

Susceptibility (Resistance to infection)

Factors which influence susceptible:

Age

Nutritional status

Chronic disease history

Trauma

Smoking

The Infectious Process

➢ Incubation Period

➢ Prodromal Stage

➢ Illness Stage

➢ Convalescence

➢ Pathogenicity of organism

➢ Localized vs. systemic

DEFENSES AGAINST INFECTION

▪ Normal flora

▪ Body System Defenses (P&P Pg.647)

▪ Inflammation VASCULAR AND CELLULAR RESPONSE

EDEMA

PHAGOCYTOSIS

LEUKOCYTOSIS

INFLAMMATORY EXUDATE

SEROUS

SANGUINOUS

PURULENT

SPECIFIC DEFENSES AGAINST

INFECTION

CELL- MEDIATED IMMUNITY

ANTIBODY-MEDIATED IMMUNITY

HEALTH CARE ASSOCIATED

INFECTION (NOSOCOMIAL)

Infections that are a result of health care

delivery, not present at admission

EXOGENOUS

ENDOGENOUS

IATROGENIC

Refer to Potter & Perry Table 34-2 Pg. 648

(Sites for Causes of HAI’s)

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Common Health-Care

Associated Infections Urinary Tract Infection

Surgical/Traumatic Wound Infection

Respiratory Tract

Bloodstream

The Nursing Process & Infection

Control (Assessment)

Status of defense mechanisms

Client Susceptibility

Nutritional Status

Stress

Disease Process

Medical Therapy

Clinical Appearance

Lab Data

Lab Data

WBC Count

Sedimentation Rate

Cultures of sputum, urine, blood

Differential Count

Assessing Risk for Infection

Age

Disease Processes

Lifestyle

Occupation

Diagnostic Procedures

Medications

Travel History

Nutritional Status

NURSING DIAGNOSIS AND

PLANNING

NANDA APPROVED DIAGNOSIS

GOALS AND OUTCOMES

MEASURABLE

REALISTIC

PRIORITIES

Acute Care Interventions

MEDICAL AND SURGICAL ASEPSIS

CONTROL/ELIMINATION OF INFECTIOUS AGENTS

CONTROL/ELIMINATION OF:

MODES OF TRANSMISSION

PORTALS OF ENTRY

RESERVOIRS

HAND HYGIENE (HCP, PATIENT, FAMILY)

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INTERVENTIONS

ISOLATION PRECAUTIONS

HYPERTHERMIA INTERVENTION

ELIMINATE UNDERLYING CAUSE

FEVER MANAGEMENT

HEALTH TEACHING

ANTIBIOTIC THERAPY

PSYCHOSOCIAL SUPPORT

HEALTH CARE RESOURCES

Isolation Precautions

CDC and OSHA Guidelines

1. Contact

1. Droplet

1. Airborne

Drug Resistant Organism Infections &

Colonizations

Methicillin-Resistant Staphylocuccus

aureus (MRSA)

Vancomycin-Resistant Enterococcus

(VRE)

Extended-Spectrum Beta Lactamase

(ESBL)

Multi-drug Resistant Tuberculosis

Personal Protective Equipment

Gowns

Respiratory Masks

Eye Protection

Gloves

Specimen Collection

Bagging Trash & Linen

Transporting Patients

EVALUATION

MEASURE SUCCESS OF INFECTION

CONTROL TECHNIQUES

COMPARE PATIENT’S RESPONSE TO

ACTUAL OUTCOME

WHAT WILL YOU DO IF

GOAL/OUTCOMES NOT ACHIEVED?

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Topic- INTESTINAL OBSTRUCTION

Presented By:-

Deepesh Bhardwaj

Associate Professor

Mahatma Gandhi Nursing College

INTESTINAL

OBSTRUCTION

INTRODUCTION

An intestinal obstruction is a potentially serious

condition in which the intestines are blocked. The

blockage may be either partial or complete, occurring at

one or more locations. Both the small intestine and large

intestine, called the colon, can be affected. When a

blockage occurs, food and drink cannot pass through the

body. Obstructions are serious and need to be treated

immediately. They may even require surgery.

DEFINITION

Intestinal obstruction is a partial or complete

blockage of the bowel that results in the failure

of the intestinal contents to pass through.

TYPES OF INTESTINAL OBSTRUCTION

Mechanical obstruction may be caused by an occlusion of the

lumen of the intestinal tract from pressure on the intestinal

walls.. Examples are intussusceptions, polypoid, hernias, and

abscess.

Functional Obstruction:

The intestinal musculature cannot propel the contents along

the bowel. Examples are amyloidosis, muscular dystrophy ,

endocrine disorders such as diabetes mellitus or neurologic

disorders such as Parkinson's disease.

ETIOLOGY/RISK FACTORS

1.Abdominal or pelvic surgery which often causes

adhesions

2.Crohn’s disease

3.Cancer within abdomen.

4.Paralytic ileus (Pseudo obstruction)

5.Twisting of the intestine (Volvulus)

6.Telescoping of the intestine (intussusception)

7.Diverticulitis

8.Impacted feces

9.Narrowing of the colon

10.Accidents

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• Blockage in the intestine

Impairment of the passage of material through the bowel

Blockage results in distention of the proximal intestine

Necrosis and perforation of the bowel.

Activation of local and systemic inflammatory responses

and translocation of bacteria through the wall of the

PATHOPHYSIOLOGY

• Blockage in the intestine

• Impairment of the passage of

material through the bowel

• Activation of local and• systemic inflammatory• responses

• and translocation of bacteria• through the wall of the

CLINICAL MANIFESTATION

Abdominal Fullness, Gas

• Abdominal pain and cramping

• Breath odor

• Constipation

• Vomiting

• Diarrhea

• Fever

• Failure to pass stool in case of paralytic • ilius• Absence of flatus

• Fatigue

• Join pain

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then go silent

DIAGNOSTIC EVALUATION

❑A thorough history and physical

examination

❑Abdominal X-rays or CT scans

❑Complete blood count and serum

electrolyte amylase and blood Urea,

nitrogen

❑Barium Enema

❑Sigmoidoscopy/ Colonoscopy

MEDICAL MANAGEMENT

passed through partially

obstructed areas

volvulus. Colon decompression catheters

may be

viacolonoscope to decompress the bowel before surgery.

Medical Management

Collaborative Care:

➢Treatment involves placing a nasogastric tube through

the nose into the stomach or intestine to help relieve

abdominal distention and vomiting

➢Before surgery, IV infusions that contain normal saline

solution and potassium should be given to maintain fluid

and electrolyte balance.

➢Sigmoidoscopy may successfully reduce a

sigmoid

SURGICAL MANAGEMENT

Laparoscopic Bowel obstruction

surgery

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COMPLICATION

Dehydration

Electrolyte imbalance

Infection

Jaundice

Perforation(hole) in the intestine

Peritonitis

Sepsis

NURSING ASSESSMENT

Take a careful history to obtain

information about current symptoms and

previous disease manifestations.

1. NURSING DIAGNOSIS

Acute pain related to abdominal distension and

increased peristalsis.GOAL

To relief pain

PLAN OF INTERVENTION

lAssess the level of pain, location, intensity, duration

l.lProvide comfortable position and promote restful environment.

Administer analgesics as advised by the physician.

EXPECTED OUTCOME

Pain will be reduced

2. NURSING DIAGNOSIS

Deficient fluid volume related to decrease in intestinal

fluid absorption and loss of fluids secondary to vomiting.

GOAL

To maintain the fluid volume.

PLAN OF INTERVENTION

Monitor Patients for signs of dehydration

A strict intake and output record should be maintain

Fluids should be administered as ordered.

EXPECTED OUTCOME

Fluid volume will be maintained.

3. NURSING DIAGNOSIS

Imbalanced nutrition less than body requirements

related to intestinal obstruction and vomiting

GOAL:

Maintation Nutrional status

PLAN OF INTERVENTION

lNasogastric tube is inserted for

l feedinglProvide liquid diet rich in protein and high caloric diet

l.lEncourage patient and assist in doing oral care

Monitor Intake output Chart

EXPECTED OUTCOME

Nutrition Status will be Maintaion

4. NURSING DIAGNOSISAnxiety related to lack of knowledge about the

disease process as evidence by asking

questions.

GOAL

To reduce the anxiety level.

PLAN OF INTERVENTION

lAssess the anxiety level of the patient.lExplain about the disease condition at the level of their understanding.

lEncourage to ventilate feelings and clear doubts if any.

lProvide psychological support.

EXPECTED OUTCOME

Anxiety level will be reduced.

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A teacher has to create learning situations & it demands

a through planning of the teaching programe. It must

be done in advance.

daily lesson plan is to guide the teacher in her teaching

activities work. Teacher must be aware of the

specialized and personal, professional growth and

objectives undertake the learning activities and kind of

evaluative devices.

“ a plan prepared by a teacher to teach a

lesson in an organized manner”

“ it is a plan of action of a teacher, which

includes the working philosophy of the teacher, her

knowledge, information about and understanding of her

pupil, her comprehension of the objectives of

education, her knowledge of the material to be taught &

her ability to utilize effective methods”

It ensures a definite objective for the days work and a

clear visualization.

Planning of the activities& the preparation of tests of

progress.

To ensure steady progress & a definite outcome of

teaching and learning procedure.

Ensure selection, presentation of subject matter &

interpretation.

Enable to chose& adopt effective method of teaching.

Enable to evaluate the teaching sessions.

Help to review the subject & give up to date

knowledge.

It help to clarify the idea.

It makes the teacher to look ahead& plan a series of

activities for modifying the learner's attitude, habit &

abilities in desirable direction.

It encourages proper consideration of learning

process & learning procedure.

It is best technique to judge the outcome of

instruction.

Serve a check on unplanned curriculum.

Continuity is assured in educative process needleless

repetition is avoided.

It help the teacher to select & organize the material,

which he want to present without anxiety in the class.

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Ensure definite association & link between various

lessons & units or past & future lessons.

It stimulate the teacher to think or related material,

illustrations & audio-visual aids to make more

relevant lively, meaningful, effective & insperational.

Develop the reasoning, imagination & decision-

making ability to the teacher.

Facilitate microteaching.

1. Preparation or introduction

2. Presentation

3. Comparison & association

4. Generalization

5. Application

6. Recapitulation

successful teaching depends upon:-

It should be written & should have clear & aim

A flexible plan should be clear & specific

Should follow maxims of teaching

New ideas must be related to those held by learners

It should contain the suitable subject matter

Provide continuity in the teaching process

It should include summery , assignment

Provide list of reference books

Prepare tests for judging the outcome of teaching

The plan should state clearly the outcomes to be

achieved including both the central & contributory

objectives.

Student-teacher central objectives – general & specific

Plan should relate each class session to the previous

work of the course

A well-organized course requires each days work to

fulfill some specific function in the realization of the

course.

The knowledge component & other such materials

1. Learning activities. E.g.. Laboratory exercise, NCPs

2. Teaching activities

3. Type of illustrative materials. E.g.audio-visual aid & instruction media.

4. Assignment

5. Reference – resource material

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6. Evaluation

7. Format of lesson plan

Title of the course

Unit

Topic

Duration

Date & time

Place

Students

Method of teaching

Audio-visual aid

Previous background of trainees

Student-teacher objectives

General

Specific

Lesson plan should act as a guide

The teacher must be master of the daily plan

Plan should be continuous growth & development

Special work

Daily class plan

enthusiasm

Time Specific objective

Content Teaching-learning activity

evaluation

Ability to read with comprehension , speed and to outline.

To take lecture notes- brief, intangible, well-organized headings.

To concentrate & disciplines.

To determine the relative importance of memorizing analyzing , reviewing.

To plan organize study time.

Certain environmental condition to be met.

THANKYOU

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Care In Neonatal Intensive Care Unit

DEEPESH BHARDWAJ

ASSOCIATE PROFESSOR

MGUMST JAIPUR

Introduction

• NICU is a very specialized unit where critically ill neonatal cared to

reduce the neonatal morbidity and mortality.

• The admission to neonatal special care unit or intensive care unit has some

criteria.

• If the neonate in the critical condition, the neonate needs the care in this

unit. Mostly from the labour wards, operation theatre and hospital or any

other referred they will be send to intensive care unit (ICU)

CRITIRIA FOR ADMISSION IN NICU:

Indications for admission to the neonatal intensive care unit are as follow.

• Low birth weight(2000gm)

• Large babies(more than or equal to 4kg)

• Birth asphyxia(Apgar score less than or equal to 6)

• Meconium aspiration syndrome.

• Severe jaundice

• Neonate of diabetic mother

• Neonatal sepsis/meningitis

• Neonatal convulsion

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• Severe congenital malformation

• O2 therapy/parenteral nutrition

• Immediate after surgery

• Cardio respiratory monitoring,

• Exchange blood transfusion

• Mother of hepatitis ‘B’ carrier

• Injured neonate ,Birth Injury

AIMS/GOALS OF NICU

• Intensive care needs highly trained personnel including the intensive care

specialist, and nurses and techniques.

• To improve the condition of the critically ill neonates keeping in mind the

survival of neonate so as to reduce the neonatal morbidity and mortality.

• To provide continuing Inservice training to medicine and nursing

personnel in the care of the new born.

• To maintain the function of the pulmonary, cardio-vascular, renal and

nervous system.

• To monitor the heart rate, body temperature, blood pressure, central

venous pressure.

• To measure the oxygen concentration of the blood is by oxygen

analyzers

• To check/observe alarms systems signal, to find out the changes

beyond certain fixed limits set on the monitors.

• To administer precise amounts of fluids and minute quantities of drugs

through I.V. infusion pumps.

PREPARATION OF NICU

• Warm (33-36°C) incubator

• Adequate light source

• Resuscitation and treatment trolly stocked.

• History, continuation sheet treatment and diet sheet,

• problem list and flow charts.

• incubator

• Oxygen air and suction apparatus (as available in the unit).

• Oxygen line connected to oxygen and air flow meter.

• Suction - tubing and various sizes of suction catheters.

• Vital signs monitors.

ADMISSION PROCEDURE IN NICU

All babies admitted to the neonatal unit. Should have the following data

carefully within 24 hours of admission (if possible much sooner).

➢ Maternal history

➢ Previous obstetric history

➢ Details of present pregnancy

➢ Labour.

➢ Delivery

➢ Apgar score

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On admission

• Notify the doctor and the nurse incharge.

• Resuscitate infant as necessary and maintain warmth.

• Check infant identification label.

• Quickly examine the infant from head to toe for obvious abnormalities

condition permits.

• Record Weight, length and head circumference as soon as possible

• Transfer to warm environment as soon as. Possible

• observations are :-

• (a) Temperature - Infant normal temperature range 36°C to 37°C

• (b) Heart rate. (c) Respiration (d) Colour, (e) Activity

Record keeping:

Birth history : Done in labour ward.

➢ Apgar score and examination of new born infant, sheet.

➢ Neonatal weight and feed sheet, progress chart.

B. Compiled history contains

➢ Patient registration form.

➢ Progress 'sheet .

➢ intra uterine growth chart

➢ 02 flow sheets

LIFE THREATENING CONDITIONS WHICH REQUIRE NICU

The following are the life threatening conditions in neonates :

▪ Apnea

▪ Baby with respiratory distress

▪ Birth asphyxia.

▪ Convulsions.

▪ Low birth weight babies (less than 1500 gm requiring intensive care.)

▪ Neonatal jaundice requiring exchange blood transfusion.

▪ Sepsis and meningitis.

HOW TO MAKE ROUND WITH THE CONSULTANT IN NICU

The nurse should have the following recording and reporting while round with consultant.

A. Examine and evaluate assigned patients (neonate) each day.

B. Record keeping:-

1. Progress notes - it should reflect present status of infants and new problems

2. Problem list - a complete problem list is kept at the front of the progress notes.

- This must be kept current, new problems listed and resolved problem also noted. - The

number of the problems in the progress chart should be consistent with the problem list.

The problems should be collected from following areas :

A. General status :-

➢Better ? Worse ? No change ?

B. Nutrition ;- Weight, Plan of nutrition (feeding)

C. Respiratory problems :-

➢Present status, laboratory findings.

D. Infection :

➢If suspected or present,

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E. Apnea :-

➢Number and severity of apneas/bradycardia.

F. Cardiovascular –

➢Blood pressure

G. Fluids and electrolytes :-

➢Intake and output

INSTRUMENTS AND FACILITIES IN NICU

• Apex institution or regional center must be equipped with

centralization supply, suction facilities, incubators/open care

system, vital signs and transmutes ventilators and infusion

pumps, which are mandatory to provide intensive neonatal care.

• The neonatologist and the nurse in charge must be involve while

planning the unit. The intensive care area should be localized

preferably next labour ward and delivery rooms. through both the

areas there must have separate adequate staff and a single

administrative control.

Physical facilities • In the case of controlling the environmental temperature, the NICU should

not - be located on the top floor, but there must be adequate sunlight for

illumination.

• The unit must have a fair degree or ventilation of fresh air through central air

conditioning is a must.

• The temperature inside the unit should be maintained at 280 -300 C

• In case the unit is responsible for picking up babies, referred from the

regional hospitals,

• it Should be within easy access for the ambulance entrance and should have

a separate elevator.

Temperature of the unit

ASPECTS OF NICUTwo main important aspects-in NICU

1) Physical ,set up

2) Administrative set up

Categories of NICU:

There are three categories:

1) First level (mild)

2) Second level (moderate)

3) Third level (critical).

PHYSICAL SET UP

• Space between the patients – For the patient care, 100 square feet is

required for each baby

• There should be a gap of about 6 feet between two incubators for

adequate circulation and keep the essential lifesaving equipment’s,

• Each patient station should have 12-16 central voltage stabilized

electric outlets.

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5

• 2 to 3 oxygen outlets.

• 2 compressed air outlets. 2 to 3 suction outlets.

• - Additional power plug point would be required for the portable

x-ray machine close to the patient care area.

Staff Requirements

• Neonatal physician - He should be available on 24 hours bases for

consultation.

• Services of other specialists like microbiologist, hematologist,

radiologist, and cardiologist and should be available on call.

• Pediatric surgeon and pediatric pathologists should be available.

Nurses Ratio:-

• Nurse patient ratio of 1:1 maintained throughout day and night.

• A ratio of one nurse for two sick babies not requiring ventilator support may be adequate.

Equipment required for any neonatal ICU

✓Resuscitation

✓ incubators

✓ infusion pumps

✓ventilators

✓O2 hoods, 02 analysers

✓Heart rate monitors

02 analysers

Resuscitation

✓ Phototherapy

✓Electronic weighing scale

✓ Pulse oximeters

✓ECG monitor

✓

✓Intracranial pressure monitors

Phototherapy

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6

• Disposable Articles Required for the NICU

• IV. sets,

• bacterial filters,

• feeding tubes,

• endotracheal tubes,

• suction catheters,

• three way adopters,

• umbilical arterial and venous catheters,

• syringes, needles

• canula,

bacterial filters

EDUCATION PROGRAMME AT NICU

• - There should be continuing medical education programmes for physicians and nurses in the form of lecturers, demonstrations and group discussions. - this should cover important issues like resuscitation, sterilization to be maintained for critically ill babies, putting in arterial catheters, conducting exchange transfusion, maintenance of ventilators etc.

• - Educational programmes covering the nurses and physician in the community should be developed.

• - There should be regular meetings with the obstetrician to discuss the perinatal condition and care.

• - Individual high risk cases.

• - Education and follow up is necessary

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1

NOSOCOMIAL INFECTION

Presented BY:-

Deepesh Bhardwaj

Associate Professor

Definition

• A dynamic process of gathering, managing,

analyzing and reporting data on events that occur in a specific population

Importance : SENIC study:

• Surveillance was the only component

essential for reducing SSI, Pneumonia,

UTI, & bacteremia.

• Other essential components:

–Sufficient no. of trained infection control

staff and A system for reporting infection

rates of SSI to surgeons.

Steps in surveillance:

• Definition of the event(s).

• Systematic collection of data.

• Summarization of data.

• Analysis & interpretation.

• Consuming the results for improvement.

Purposes of the surveillance-1

1. Reducing the infection rate

within a hospital.

2. Establishing endemic

(baseline) rates.

3. Identifying outbreaks.

Purposes of the surveillance-2

4. Convincing medical staff.

5. Satisfying regulators.

6. Defending malpractice claims.

7. Comparing infection rates among hospitals.

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Surveillance methods-1

1.Concurrent

2.Retrospective

Concurrent

• Flexible,

• Informative

• Timely

• Capable of cluster detection

• Capable of changing behavior

• But expensive

• Depends on completeness, validity

& accuracy of existing data.

• Does not identify problems as

promptly as concurrent does.

• But isn’t expensive.

Retrospective Surveillance methods-2

•Active :• accurate

• complete

• expensive

•Passive :• misclassification

• underreporting

• lack of timeliness

• less expensive

Surveillance methods-3

• Hospital wide.

• Periodic.

• Targeted.

• Defining the threshold limit.

• Post discharge.

Hospital wide surveillance

Sources of data:

1. Daily reports of microbiology labs.

2. Medical records of febrile patients.

3. Medical records of patients taking antibiotics.

4. Medical records of isolated patients

5. Daily interview with nurses & patients

6. Periodic review of autopsy reports

7. Periodic review of medical records of staff.

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3

Periodic surveillance(S.):

Hospital wide (H.W.S) during specified periods,

And ,– Targeted S. during alternate periods

Or ,– Rotating H.W.S. from one unit to another

Targeted surveillance

• Focuses its effort on :– Selected geographic area (e.g. ICU)

– Selected service (e.g. cardio thoracic surgery)

– Specific populations of patients or infections:

• At high risk of acquiring infection ( e.g.

transplantation)

• Undergoing specific interventions( e.g.

dialysis)

• At specific site (e.g. blood stream)

Characteristics of targeted S.

• High accuracy & efficiency .

• Incapable of detecting other infections .

• Criteria for selection of target :

– Frequency.

– mortality & morbidity .

– Cost.

– preventability.

Defining the

threshold limits

Case finding issues

• Total chart review (standard method).

• Laboratory reports.

• Clinical ward rounds (twice a week).

• Kardex screening (once or twice a week).

• Fever chart.

• High risk patients (transplant, diabetic, leukemia, invasive methods, .. )

Analysis-1

• The data should be analyzed.

• The analysis should be done by staff

engaged in surveillance.

• Staff should decide how frequently to

analyze the data:

– Frequently enough to detect clusters promptly.

– Collecting the data for a long enough period of

time for changes to be meaningful.

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Analysis-2

Numerator &

Denominator

Overall rate =

No. of NI

Total no. of admitted or discharged patients

Adjusted rates

• For severity of illness.

• For length of stay.

• For exposure to device (e.g. ventilator)

Essential numerator data:

• Demographic :–name, age, sex , service, ward,admission

date, hospital identification number .

• Infection :–onset date , site of infection.

• Laboratory :–pathogen antibiogram

Numerator data : Risk factors

“only when these data used for

analysis”

• An example for SSI:

• Kind of surgery.

• Date of surgery.

• Duration of surgery.

• Type of wound (clean ,dirty, …).

• Date of discharge.

Denominator data:

Total no. of admitted or discharged pts.

ORNo. of days of exposure :

– Total no. of pts. & pt-days in the unit,

– Total no. of ventilator days,

– Total no. of central line days,

– Total no. of urinary catheter days.

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5

Comparing rates necessary assumptions:

• Same definitions.

• Same methods of S. & case finding.

• Same accuracy of methods & personnel.

• Same characteristics of hospitals/wards:

– Length of stay,

– Risk indices,

– exposure to devices,

– ...

“Dissemination” “Surveillance is not complete

until the results are

disseminated to those who use

it to prevent and control”

dissemination - continued

• Confidentiality must be regarded

• Regular time intervals for reporting .

• Format of reports :

–Summary , table , graph

Evaluation• At least annually ask yourself :

– Did the system detect clusters ?

– Which practices were changed based on S. ?

– Were the data used to decrease the endemic

rate ?

– Were the data used to assess the efficacy of

interventions ?

– Are administrative & clinical staff aware of

Surveillance Findings ?

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1

PROTIEN ENERGY MALNUTRION

PRESENTED BY:-

Deepesh Bhardwaj

Associate Professor

• Protein Energy Malnutrition (PEM) is the deficiency of macronutrients or energy and protein in the diet.

• It is a nutritional disorder, which affects all the segments of population like children, women and adult males particularly from the backward and downtrodden communities.

TYPES-

• Kwashiorkor

• Marasmus

• Marasmus kwashiorkor

KWASHIORKOR

• Kwashiorkor is an African word, meaning a "disease of the displaced child", who is deprived of adequate nutrition.

• Mostly in children between the ages of 1 and 3 years, when they are completely weaned (taken off the breast).

• The three essential manifestations or signs of kwashiorkor are:

1. Oedema (swelling of feet)

2. Growth failure, and

3. Mental changes.

SIGNS OF KWASHIORKOR

1. Oedema:

2. Growth retardation

3. Mental changes

4. Hair changes

5. Skin changes

6. Micronutrient deficiencies

MARASMUS

• Marasmus is common in children below the age of 2 years.

• The marasmic children are so weak that they may not have even energy to

cry, which most often is barely audible.

• The child is extremely wasted with very little subcutaneous fat with the skin

hanging loosely particularly over the buttocks.

• Oedema is absent and there are no skin and hair changes.

• However, frequent diarrhoeal episodes leading to dehydration and

micronutrient deficiencies of vitamin A, iron and B-complex are common.

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• Signs and Symptoms of Marasmus

• Extreme muscle wasting - "skin and bones"

• Loose and hanging skin folds

• Old man's or monkey faces

• Absolute weakness

MARASMIC KWASHIORKOR

• Sometimes,, malnourished children features of both kwashiorkor and

marasmus..

• These children will have extreme wasting of different degrees (representing

marasmus) and also oedema (a sign of kwashiorkor).

• Signs and symptoms of Marasmic Kwashiorkor

• Extreme muscle wasting - "skin and bones"

• Loose and hanging skin folds

• Old man's or monkey's face

• Absolute weakness

• Oedema

TREATMENT

Diet

• Treatment of cases of kwashiorkor or marasmus The child should receive a

diet that provides adequate amounts of energy and protein. Both of these are

required in larger quantities than normal.

The child should be given the following concentrations:

• Energy : 170 - 200 kcal per kg of body weight

• Protein : 3 - 4 g/kg of body weight

• Vitamin and mineral supplements

• Iron (60 mg) and folic acid (100 mg) may be given daily to correct anaemia.

Oral rehydration

• Since diarrhoea is very common in severe PEM, correction of dehydration is the first step in the treatment.

• Home made (salt-sugar mixture) or commercial oral rehydration solution (ORS) can be administered to correct dehydration.

• Intravenous fluids are required only in severe dehydration.

Control of infections and infestations

• Appropriate antibiotics should be started immediately since infections are the immediate cause of death in many children.

• Children with intestinal infestations Like giardiasis and ascariasis should be treated.

"prevention is better than cure". So it becomes extremely

important that we make sincere efforts to prevent and control PEM

SUPPLEMENTARY FEEDING PROGRAMMES

• Food supplementation programmes have a very important role to play to combat malnutrition.

• The aim of these supplementary feeding programmes is to improve the nutritional status of vulnerable groups through distribution of food supplements.

Following supplementary feeding programmes :

1. National Programme of Nutritional Support to Primary Education (Mid Day Meal Programme)

2. Special Nutrition Programme

3. Pradhan Mantri's Gramodaya Yojana (PMGY)

4. Balwadi Feeding Programme

5. Composite Nutrition Programme, and

6. Applied nutrition programme

MID DAY MEAL PROGRAMME

• The National Programme of Nutritional Support to Primary Education commonly

known as Mid Day Meals Scheme was launched in August, 1995

• The mid day meal programme is one of the most important ongoing feeding

programmes

• organized by the Department of Education not only to improve nutritional status of

school children but also to attract poor children to school.

Objectives

• The programme is intended to give a boost to universalization of primary education

by increasing enrolment, retention and attendance and simultaneously impacting

upon nutritional status of students in primary classes.

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SPECIAL NUTRITION PROGRAMME

• The Special Nutrition Programme was launched by the Central Social Welfare

Board (CSWD) in 1970-71.

• The aim of the programme was to provide supplementary nutrition to children,

pregnant women and nursing mothers belonging to the weaker sections of the

society.

• The main component of the programme was food supplementation.

• The supplement consisted of 300 Kcal and 10 g protein for children and 500 Kcal

and 25 g protein for Pregnant- lactating women. Feeding of the beneficiaries was

undertaken for 300 days a year.

• In addition to supplementary feeding, the scheme also included periodic health

check ups for the beneficiaries.

PRADHAN MANTRI'S GRAMODAYA YOJANA (PMGY)

• In order to achieve the objective of sustainable human development at

the village level, a new initiative in the form of Pradhan Mantri's

Gramodaya Yojana (PMGY) has been introduced in the Annual Plan

2000-01.

• Schemes related to health, nutrition, education, drinking water, housing

and rural roads are undertaken within this programme

• The PMGY has two components: Prograrmmes for rural connectivity

with 50 percent allocation, and other programmes of primary health,

primary education, rural shelter, rural drinking water and nutrition with

the remaining 50 percent allocation.

BALWADI FEEDING PROGRAMME

• Like the Special Nutrition Programme , the Balwadi Feeding Programme was also

launched in 1970-71.

• Although the Special Nutrition Programme is no longer in operation, the Balwadi Feeding

Programme remains one of the ongoing programmes -implemented through the voluntary

organizations.

• The beneficiaries of the programme include preschool children attending the Balwadi. The

services provided under the programme are supplementary feeding, regular health check-

ups, immunization, habit formation and socialization through games and recreation.

• The nutrition programme also has an educative value as it brings together several children

of the same age and is expected to inculcate good habits and help children develop taste for

different types of foods.

COMPOSITE NUTRITION PROGRAMME

• The Composite Nutrition Programme was a feeding programme launched by the

Department of Community Development, with the main objective of providing

nutrition education to the masses.

• The core of the programme was nutrition education and its particular application

through demonstration feeding.

• The programme had five components:

1. Nutrition education through mahila mandals

2. Encouragement of economic activities of mahila mandals ,

3. Strengthening 'the supervisory machinery for women's programme

4. Training of associate women workers, and

5. Demonstration feeding

APPLIED NUTRITION PROGRAMME

• The Applied Nutrition Programme was one of the first national nutrition programmes launched in 1963 through the Community Development Department,

• Aimed at improving the nutrition of lactating and pregnant women and children.

• The programme was developed 'to educate rural people about how they can increase and improve their food supply through their own efforts'.

The main objectives of the programme were:

1. To encourage production of body-building foods (such as eggs, fish, milk etc.) and

protective foods (such as vegetables, fruits), and

2. To provide nutrition education, so as to promote consumption of the body-building

protective foods by mothers and children.

THE END

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1

Route of Drug Administration

Presented By-

Deepesh Bhardwaj

Associate Professor

Route of administration

• Is the path by which a drug, fluid, poison or other substance is brought into contact with the body

• The possible routes of drug entry into the body may be divided into two classes:

– Enteral Route

– Parenteral Route

– Other Routes

Routs of Drug

administrationParenteral Route of Drug Administration

• Parenteral Routes:An injection is an infusion method of putting liquid into the

body, usually with a hollow needle and a syringe which ispierced through the skin to a sufficient depth for thematerial to be forced into the body.

There are several methods of injection, including:

• Intravenous bolus (IV)

• Intravenous infusion (IV inf)

• Intramuscular injection (IM)

• Subcutaneous injection (SC)

Parenteral Routes– Intravascular (IV)- placing a drug directly into the

blood stream; the only systemic route with no membrane to cross.

– Intramuscular (IM) - drug injected into skeletal muscle

– Subcutaneous - Absorption of drugs from the subcutaneous tissues

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2

Enteral Routes

• Enteral - drug placed directly in the GI tract:– sublingual (SL)- placed under the tongue– oral - swallowing (p.o.)– rectum (PR) - Absorption through the rectum

Other Routes• Transdermal• Inhalation • Intranasal• Ophthalmic

• Complete (100%) systemic drug absorption.

• Rate of bioavailability considered instantaneous.

• Drug is given for immediate effect.

• Increased chance for adverse reaction.

• Possible anaphylaxis

Intravenous bolus (IV(

Intravenous infusion (IV inf)

• Complete (100%) systemic drug absorption.

• Rate of drug absorption controlled by infusion rate.

• Plasma drug levels more precisely controlled.

• May inject large fluid volumes.

• Requires skill in insertion of infusion set .

• Tissue damage at site of injection (infiltration, necrosis, or sterile abscess).

Intramuscular injection (IM(

• Rapid absorption from aqueous solution.

• Slow absorption from nonaqueous (oil) solutions.

• Larger volumes may be used compared to subcutaneous solutions.

• Easier to inject than intravenous injection.

• Irritating drugs may be very painful.• Different rates of absorption depending on muscle

group injected and blood flow.

Subcutaneous injection (SC(

• Prompt absorption from aqueous solution.

• Slow absorption from repository formulations.

• Generally, used for insulin injection.

• Rate of drug absorption depends on blood flow and injection volume .

Oral (PO(

• Absorption may vary.

• Generally, slower absorption rate compared to IV bolus or IM injection.

Advantages:

• Safest and easiest route of drug administration.

• Variety of dosage forms available and may use immediate-release and modified-release drug products

• Convenient - portable, no pain, easy to take..

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3

Oral (PO( Disadvantages

• Drugs may have erratic absorption,

• Drugs may be unstable in the gastrointestinal tract, it is destructed by gastric acid and digestive juices

• Drug may be metabolized by liver prior to systemic absorption "first-pass" effects.

• Sometimes inefficient - high dose or low solubility drugs may suffer poor availability, only part of the dose may be absorbed.

• unable to use in unconscious patient.

First-pass Effect• The first-pass effect Is the term used for the hepatic metabolism

of a pharmacological agent when it is absorbed from the gut and

delivered to the liver via the portal circulation.

The greater the first-pass effect, the less the agent will reach

the systemic circulation when the agent is administered orally

• After a drug is swallowed, it is absorbed by the digestive system and enters the hepatic portal system. It is carried through theportalvein into the liver before it reaches the rest of the body. The liver metabolizes many drugs, sometimes to such an extent that only a small amount of active drug emerges from the liver to the rest of the circulatory system. This first pass through the liver thus greatly reduces the bioavailability of the drug.

Buccal or sublingual (SL)

• Sublingual administration is where the dosage form is placed under the tongue

• Buccal administration is where the dosage form is placed between gums and inner lining of the cheek.

• Rapid absorption from lipid-soluble drugs

• No "first-pass" effects.

• Some drugs may be swallowed.

• Not for drugs with high doses.

• Irritation of oral mucosa

• Drug taste may need to be masked.

USED FOR :

1. unconscious patients and children

2. if patient is nauseous or vomiting

3. good for drugs affecting the bowel

such as laxatives

RectalRectal (PR(

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Rectal (PR(

• Absorption may vary from suppository.

• More reliable absorption from enema solution.

• Useful when patient cannot swallow medication

• Used for local and systemic effects.

• Absorption may be erratic .

• Some patient discomfort.

Transdermal

• Slow absorption, rate may vary.

• An occlusive dressing may be used to improve absorption.

• lower risk of side effects

• Transdermal delivery system (patch) is easy to use.

• It could achieve systemic or local effects.

• Used for lipid-soluble drugs with low dose and low MW.

• Skin irritation from the patch or drug .

• Permeability of skin variable with condition, anatomic site, age, and gender .

• Type of cream or ointment base affects drug release and absorption.

Transdermal Disadvantages Inhalation and intranasal

• Rapid absorption.

• Total dose absorbed is variable .

• May be used for local or systemic effects.

• May stimulate cough reflex.

• Some drug may be swallowed.

• When a drug is administered by an extravascularroute of administration (eg, oral, topical, intranasal,inhalation, rectal), the drug must first be absorbedinto the systemic circulation and then diffuse or betransported to the site of action before elicitingbiological and therapeutic activity.

• The general principles and kinetics of absorptionfrom these extravascular sites follow the sameprinciples as oral dosing, although the physiology ofthe site of administration differs .

• Many drugs are not administered orally because ofdrug instability in the gastrointestinal tract or drugdegradation by the digestive enzymes in the intestine.

• Erythropoietin and human growth hormone areadministered IM, and insulin is administered SC orIM, because of the potential for degradation of thesedrugs in the stomach or intestine.

• Biotechnology products are too labile to beadministered orally and are usually givenparenterally.

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• Drug absorption after subcutaneous injection is slower than intravenous injection.

• Pathophysiologic conditions such as burns will increase the permeability of drugs across the skin compared with normal intact skin.

• The systemic absorption of a drug is dependent on:

• (1) the physicochemical properties of the drug,

• (2) the nature of the drug product,

• (3) the anatomy and physiology of the drug

absorption site.

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1

Nursing Care Of the

hospitalized child

Presented By:-Deepesh Bhardwaj

Associate Professor

Hospitalization of the child

◼ The act of putting a child in the hospital to a

child already coping with illness.

◼ With hospitalization comes a

– change from the usual state of health

– Change in routine

Stressors of Hospitalization

◼ Separation from family

◼ Change of environment

◼ Loss of control

◼ Bodily injury and pain

Risk Factors That Increase Vulnerability

to Stressors of Hospitalization

◼ “Difficult” temperament

◼ Lack of fit between child and parent

◼ Age (especially from 6 months to 5 years)

◼ Male gender

◼ Below-average intelligence

◼ Multiple and continuing stresses (e.g.,

frequent hospitalizations)

Changes in the Pediatric Population

◼ More serious and complex problems

◼ Fragile newborns

◼ Children with severe injuries

◼ Children with disabilities who have survived because of increased technologic advances

◼ More frequent and lengthy stays in hospital

Infants and Toddlers

◼ Parent child relationship is disturbed

◼ Change in routine promotes distrust

◼ Separation anxiety (6 to 30 months)

– Protest phase

▪ Cry and scream, cling to parent

– Despair phase

▪ Crying stops; evidence of depression

– Detachment phase

▪ Denial; resignation, not contentment

▪ May seriously affect attachment to parent after separation

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Separation anxiety

◼ Nursing Interventions– Preserve trust

– Reassure child parents will return

– Provide place for parent to stay in hospital to promote attachment

– Have parents leave personal articles with child (pictures, toys, cloths etc.)

– Maintain pre-hospital routines and rituals when possible.

– Return control to parent and child by providing choices.

Protest Phase of Separation Anxiety

Despair Phase of Separation Anxiety

Loss of Control: Infants’ Needs

◼ Trust

◼ Consistent loving caregivers

◼ Daily routines

Loss of Control: Toddlers’ Needs

◼ Autonomy

◼ Daily routines and rituals

◼ Loss of control may contribute to:

– Regression of behavior

– Negativity

– Temper tantrums

Young Infant’s Response to Pain

◼ Generalized response of rigidity, thrashing

◼ Loud crying

◼ Facial expressions of pain (grimace)

◼ No understanding of relationship between stimuli and subsequent pain

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3

Facial Expression of Physical Distress

Older Infant’s Response to Pain

◼ Withdrawal from painful stimulus

◼ Loud crying

◼ Facial grimace

◼ Physical resistance

Pain Scale- FLACC

0 1 2

Face No expression or smile

Occasional grimace or frown/withdrawn/ disinterested

Frequent to constant frown, clenched jaw, quivering chin

Legs Normal position/relaxed

Uneasy/ restless/tense

Kicking or legs drawn up

Activity Laying quietly/normal position/ moves easily

Squirming/ shifting back and forth/ tense

Arched rigid or jerking

Cry No Cry Moans or whimpers/ occasional complaint

Crying steadily, screams or sobs, frequent complaint

Consolability Content/relaxed Reassured by occasional touching/ hugging/ talking to/ distractible

Difficult to console or comfort

Infants and Toddlers

◼ Regression- common in toddlers and young children

Preschooler

◼ Fear mutilation

◼ Egocentric, present oriented

◼ Sees illness as punishment

◼ Separation anxiety still exists

◼ May show signs of regression

Loss of Control: Preschoolers

◼ Egocentric and magical thinking typical of age

◼ May view illness or hospitalization as punishment for misdeeds

◼ Preoperational thought

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4

Preschooler nursing interventions

◼ Encourage parents to participate in care

◼ Give simple explanations

◼ Provide therapeutic play

◼ Allow child to play with equipment

◼ Praise the child, give rewards (stickers)

Young Child’s Response to Pain

◼ Loud crying, screaming

◼ Verbalizations: “Ow,” “Ouch,” “It hurts”

◼ Thrashing of limbs

◼ Attempts to push away stimulus

◼ May deny pain for fear of an injection

◼ Often can describe location and intensity of pain

Pain Scale - FacesPreventing or

Minimizing Separation◼ Primary nursing goal

◼ Especially for children younger than 5 years

◼ Family-centered care

◼ Parents are not “visitors”

◼ Familiar items from home

Mothers Are the Usual Family Caregivers

Providing Comfort to Hospitalized Child

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5

School-age

◼ Fear: Pain, bodily injury and loss of control

◼ Fears are often related to school peers and family

◼ Will ask relevant questions and want to know reasons for tests etc.

◼ Have a more realistic understanding of there disease

◼ Become stressed over separation from family and peers.

School age child

◼ Vulnerable to events that lessen their feelings of control and power

◼ Hospital activities that limit control may be a direct threat to children’s security

◼ Allow children to exert control whenever possible

◼ Boredom is a big problem with hospitalized children

Interventions

◼ Communicate openly, explain rules

◼ Clarify misconceptions

◼ Encourage self care

◼ Allow peers and siblings to visit

◼ Age appropriate therapeutic play

◼ Provide explanations; use visual aids

◼ Praise child, focus on behavior

Pain

◼ Able to describe pain

◼ Become concerned with disability and death

◼ May bite, kick, cry when in pain

◼ Stalling behavior (“wait a minute”)

◼ Muscle rigidity

◼ May use all behaviors of young child

Adolescents◼ Fear: Loss of independence, loss of identity, body

image disturbance, rejection by others

◼ Separation from peers is a source of anxiety

◼ Physical appearance is of great importance

◼ May be reluctant to ask questions, may fear being lied to, may verify information from multiple sources to be sure others are being truthful

◼ Often feel they are “invincible” which puts them at risk for noncompliance and risk taking behaviors

Loss of Control: Adolescents

◼ Struggle for independence and liberation

◼ Separation from peer group

◼ May respond with anger, frustration

◼ Need for information about their condition

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6

Adolescent

◼ Less vocal protest, less motor activity

◼ Increased muscle tension and body control

◼ More verbalizations (“It hurts,” “You’re hurting me”)

Interventions

◼ Involve adolescent in plan of care

◼ Support relationship with family and peers

◼ Provide consistent and truthful explanations

◼ Accept emotional outbursts

◼ Promote communication between adolescent and family

Family

◼ Hospitalizing a child adds stress and anxiety to the entire nuclear family including:

– Parents

– Siblings

◼ A child being hospitalized may also change family Roles

Parental Responses to Stressors of Hospitalization

◼ Disbelief, anger, guilt

– Especially if sudden illness

◼ Fear, anxiety

– Related to child’s pain, seriousness of illness

◼ Frustration

– Especially related to need for information

◼ Depression

Sibling Reactions

◼ Loneliness, fear, worry

◼ Anger, resentment, jealousy

◼ Guilt

Altered Family Roles

◼ Anger and jealousy between siblings and ill child

◼ Ill child obligated to play sick role

◼ Parents continue pattern of overprotection and indulgent attention

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7

What We Can Do For Child

◼ Prevent or minimize separation

– Parent Participation, minimize effects of separation

◼ Minimize loss of control

– Promote free movement, Maintain routine, encourage independence

◼ Prevent or minimize Bodily Injury

◼ Provide Developmental Activities

◼ Use Play to Decrease Stress

◼ Maximize Benefits of hospitalization

Family Presence During Hospitalization

Providing Developmentally Appropriate Activities

◼ Using play/expressive activities to minimize stress

– Divisional activities

– Toys

– Expressive activities

– Play therapy

– Dramatic play

Using Play to Ease Children’s Fears

“Normalizing” the Hospital Environment

◼ Promote freedom of achievement

◼ Maintain child’s routine, if possible

◼ Time structuring

◼ Self-care (age appropriate)

◼ Schoolwork

◼ Friends and visitors

Maximizing Potential Benefits of Hospitalization

◼ Fostering parent-child relationships

◼ Providing educational opportunities

◼ Promoting self-mastery

◼ Providing socialization

◼ Supporting family members

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8

What we Can do for Family

◼ Family centered care

◼ Provide information

Assessment Techniques

◼ Newborn

◼ Infant

◼ Toddler

◼ Preschool

◼ School age

◼ Adolescent

Newborn History and PE

◼ Maternal History important!

◼ PE– Do all you can with infant asleep ie RR, HR

listen to abdomen etc

– Umbilical cord needs to be checked

– Continue to check fontanels

– Hr 100-170

– RR 30-80

– BP 73/55

Infant History and PE

◼ Maternal history and birth process still addressed

◼ All History from mother

◼ Continue to assess all possible while infant is asleep

◼ Play with older infants

◼ May be more comfortable being assessed in mothers arms

Toddler History and PE

◼ Maternal and birth history continue to be important

◼ Establish relationship with mom before trying to talk to child

◼ Allow child to play with equipment prior to use if possible

◼ Do not separate child from parent!

◼ May play with toddlers

◼ Allow parent to help when possible with assessment (may need mom to move stethoscope around chest)

◼ Stranger/ separation anxiety!!!!

Average VS

◼ 12 month

– HR 80-130

– RR 20-40

– BP 90/56

◼ 24 month

◼ HR 70- 120

◼ RR 20-40

◼ BP 90/56

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9

Preschool History and PE

◼ Children tend to be more outgoing, cooperative

◼ Explain procedures prior to starting, allow child to play with equipment

◼ Use distraction!

◼ Vital signs 3-5 years– HR 70-120

– RR 20-30

– BP 92/55

School age History and PE

◼ Children become aware of the difference in sexes, privacy becomes important!

◼ Vitals 6-9 years– HR 70-110– RR 16-22– BP @ 6 years 96/57– BP @ 9 years 100/61

◼ Vitals 10-12 years– HR 60-100– RR 16-20– BP@12yrs 107/64

Teen History and PE

◼ History comes from teen, not from parent

◼ Want to be treated more like an adult

◼ Do not Talk down to pt no “honey” or “sweetie” etc.

◼ Ask if they want parent in the room for exam.

◼ Ask about drug use, sexual activity without parent in room!

◼ Confidentiality!

PE Adolescent

◼ Vitals 13-14 years– HR 60-100

– RR 16-20

– 107/64

◼ Vitals 15- 18 years– HR 60-100

– RR 12-20

– BP 114/65

– BP@ 18 121/70

General Hygiene and Care

◼ Skin care

– Bathing

◼ Oral hygiene

◼ Hair care

◼ Feeding

◼ Temperature management

Supporting Infant During Tub Bath

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10

Safety

◼ Name bands

◼ Patient identity

◼ Environment

◼ Activity supervision

◼ Hugs tags

Nurse Maintains Hand Contact

Carrying InfantsTransporting Peds Patients

◼ Infants must be in bassinet

◼ Older kids in

wheelchairs, stretchers, and “buggies”

◼ .

Restraining Methods

◼ Therapeutic hugging

◼ Mummy or swaddle restraint

◼ Limb restraints

◼ Papoose board

Therapeutic Hugging for Extremity Vein Puncture

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11

Mummy Restraint Elbow Restraints

Papoose Board

.

SPECIMEN COLLECTION

◼ Urine

◼ Stool

◼ Blood

◼ Sputum

Application of a Urine Collection Bag

Puncture Site on Sole of Infant’s Foot

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12

The EndReferences

◼ Hockenberry, M. J., Wilson, D., (2015) Wong’s Nursing Care of Infants and Children 10th Edition. Mosby, St Louis MO.

◼ Hogan, M. A., White, J. E., Falkenstein, K., Brancato, V., (2007) Child Health Nursing Reviews & Rationales 2nd Edition. Prentice Hall, Upper Saddle River, NJ.

◼ Johns Hopkins Hospital (2005) The Harriet Lane Handbook 7th Edition. Mosby Philadelphia PA.

◼ Wilson, D., Hockenberry, M. J., (2008) Wong’s Clinical

Manual of Pediatric Nursing 7th Edition. Mosby, St Louis MO.

.

1

VITAL SIGNS

Presented By:-

Deepesh Bhardwaj

Associate Professor

TEMPERATURE

PULSE

RESPIRATIONS

BLOOD PRESSURE

VITAL SIGNS MUST BE MEASURED, REPORTED, AND

RECORDED ACCURATELY

IF YOU ARE NOT SURE OF A MEASUREMENT,

RECHECK IT

o WHEN A PERSON IS ADMITTED TO A HEALTH CARE

FACILITY

o SEVERAL TIMES A DAY FOR HOSPITALIZED PATIENTS

o BEFORE AND AFTER SURGERY

o AFTER SOME NURSING PROCEDURES

o BEFORE MEDICATIONS ARE GIVEN THAT AFFECT THE

RESPIRATORY OR CIRCULATORY SYSTEM

o WHENEVER THE PERSON COMPLAINS OF PAIN,

SHORTNESS OF BREATH, RAPID HEART RATE, OR NOT

FEELING WELL

o WITH THE PERSON AT REST IN A LYING OR SITTING

POSITION

o ILLNESS

o EMOTIONS – ANGER, FEAR, ANXIETY, PAIN

o EXERCISE AND ACTIVITY

o AGE

o SEX

o ENVIRONMENT - WEATHER

o FOOD AND FLUID INTAKE

o MEDICATIONS

o TIME OF DAY – ↓ IN THE MORNING, ↑ IN THE AFTERNOON/EVENING

o NOISEA CHANGE IN ONE VITAL SIGN WILL CAUSE A CHANGE IN

THE OTHERS

o ANY VITAL SIGN IS CHANGED FROM A PREVIOUS

MEASUREMENT

o VITAL SIGNS ARE ABOVE THE NORMAL RANGE

o VITAL SIGNS ARE BELOW THE NORMAL RANGE

MANY AGENCIES HAVE TEMP BOARDS OR TPR BOOKS

RECORD VITAL SIGN MEASUREMENTS AS SOON AS

POSSIBLE

CARRY A SMALL NOTEBOOK IN YOUR POCKET SO YOU

CAN RECORD THEM AS YOU TAKE THEM

ABBREVIATIONS

TEMPERATURE – T

PULSE – P

RESPIRATIONS – R

BLOOD PRESSURE - BP

.

2

RESPOND TO PATIENT OR VISITOR

QUESTIONS ABOUT VITAL SIGNS

ACCORDING TO FACILITY POLICY

REFER THEIR QUESTIONS TO THE

NURSE

BODY TEMPERATURE IS THE AMOUNT OF HEAT IN THE

BODY

IT IS A BALANCE BETWEEN THE AMOUNT OF HEAT

PRODUCED AND THE AMOUNT OF HEAT LOST

HEAT IS PRODUCED BY :

THE CONTRACTION OF MUSCLES DURING EXERCISE

THE BREAKDOWN OF FOOD DURING DIGESTION

THE ENVIRONMENTAL TEMPERATURE

HEAT IS LOST THROUGH :

URINE FECES

RESPIRATIONS PERSPIRATION

BODY TEMPERATURE IS MEASURED IN ONE OF FOUR

AREAS OF THE BODY

THE MOUTH – ORAL

THE RECTUM – RECTAL

THE AXILLA (UNDERARM) – AXILLARY

THE EAR – TYMPANIC

WE NOW ALSO HAVE THE TEMPORAL SITE - FOREHEAD

MOST TEMPERATURES ARE TAKEN ORALLY

RECTAL TEMPERATURES ARE THE MOST ACCURATE

AXILLARY TEMPERATURES ARE THE LEAST ACCURATE

SITE NORMAL RANGE

ORAL 98.6 ° 97.6 ° TO 99.6 °

RECTAL 99.6 ° 98.6 ° TO 100.6 °

AXILLARY 97.6 ° 96.6 ° TO 98.6 °

TYMPANIC 98.6 ° 98.6 °

TEMPORAL 98.6° 98.6°

A SMALL HOLLOW GLASS TUBE THAT CONTAINS

MERCURY OR A MERCURY-FREE SUBSTANCE IN A BULB

AT ONE END.WHEN HEATED THE MERCURY RISES IN

THE TUBE.

Pear – shaped tip

o THE SCALE IS MARKED FROM 94° TO 108°

o THE LONG LINES REPRESENT ONE DEGREE

o THE SHORT LINES REPRESENT TWO TENTHS OF A DEGREE

o ONLY EVERY OTHER DEGREE IS MARKED WITH A NUMBER

.

3

o BATTERY OPERATED

o HAVE AN ORAL PROBE AND A RECTAL PROBE

o DISPOSABLE PROBE COVER IS PLACED ON THE PROBE

o THE TEMPERATURE REGISTERS IN ABOUT 30 SECONDS

USE A DISPOSABLE SHEATH

o MEASURES THE TEMPERATURE IN THE TYMPANIC MEMBRANE (EARDRUM)

o FAST AND ACCURATE - 1 TO 3 SECONDS

INFANTS – PULL

THE EAR

STRAIGHT BACK

ADULTS AND

CHILDREN OVER

ONE YEAR –

PULL THE EAR UP

AND BACK

GLASS

THERMOMETER

o RINSE WITH COLD WATER

o CHECK THE THERMOMETER

FOR BREAKS AND CHIPS

o SHAKE DOWN THE

THERMOMETER SO THE

MERCURY IS BELOW THE LINES

AND NUMBERS

o PLACE A DISPOSABLE COVER

ON THE THERMOMETER

o PLACE THE THERMOMETER

UNDER THE PERSON’S TONGUE

o LEAVE THE THERMOMETER IN

PLACE FOR 2 – 3 MINUTES

o IF THE PERSON HAS BEEN

EATING, DRINKING, OR

SMOKING, WAIT 15 MINUTES

BEFORE TAKING TEMPERATURE

DO NOT TAKE AN ORAL TEMPERATURE ON:

o AN INFANT OR YOUNG CHILD ( UNDER AGE 6)

o AN UNCONSCIOUS PATIENT

o A PATIENT THAT HAS HAD ORAL SURGERY OR AN INJURY TO THE FACE,

NECK, NOSE, OR MOUTH

o A PERSON RECEIVING OXYGEN

o A PATIENT WITH A NASOGASTRIC TUBE IN PLACE

o A PATIENT WHO IS CONFUSED OR RESTLESS

o A PATIENT WHO IS PARALYZED ON ONE SIDE OF THE BODY

o HAS A HISTORY OF SEIZURES

o A PATIENT WHO BREATHES THROUGH THE MOUTH

o LUBRICATE THE THERMOMETER BEFORE INSERTING INTO THE RECTUM

o PLACE THE PERSON IN A SIDE-LYING POSITION

o INSERT THE THERMOMETER 1 INCH INTO THE RECTUM

o HOLD THE THERMOMETER IN PLACE FOR 2 MINUTES

o REMOVE THE DISPOSABLE COVER AND READ THE THERMOMETER

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4

DO NOT TAKE A RECTAL TEMPERATURE ON:

o A PERSON WHO HAS HAD RECTAL SURGERY OR RECTAL INJURY

o IF THE PERSON HAS DIARRHEA

o IF THE PERSON IS CONFUSED OR AGITATED

o IF THE PERSON HAS HEART DISEASE ( STIMULATES THE VAGUS NERVE

WHICH SLOWS THE HEART RATE )

o TAKEN ONLY WHEN NO OTHER SITE CAN

BE USED

o MAKE SURE THE UNDERARM IS CLEAN

AND DRY

o THE ARM IS HELD CLOSE TO THE BODY

o YOU NEED TO HOLD THE THERMOMETER

IN PLACE WHILE THE TEMPERATURE IS

BEING TAKEN

o THE THERMOMETER IS LEFT IN PLACE

FOR 10 MINUTES

THE PULSE IS:

o THE BEAT OF THE HEART FELT AT AN ARTERY AS A WAVE OF BLOOD PASSES

THROUGH THE ARTERY

o A PULSE IS FELT EVERY TIME THE HEART BEATS

o MORE EASILY FELT IN ARTERIES THAT COME CLOSE TO THE SKIN AND CAN

BE GENTLY PRESSED AGAINST A BONE

o THE PULSE SHOULD BE THE SAME IN ALL PULSE SITES ON THE BODY

o THE PULSE IS AN INDICATION OF HOW THE CARDIOVASCULAR SYSTEM IS

MEETING THE BODY’S NEEDS

o THE PULSE RATE IS AFFECTED BY MANY FACTORS – AGE, FEVER,

EXERCISE, FEAR. ANGER, ANXIETY, EXCITEMENT, HEAT, POSITION, AND PAIN.

o MEDICATIONS CAN BE TAKEN THAT EITHER INCREASE OR DECREASE A

PERSON’S PULSE RATE.

WE USUALLY COUNT A PULSE FOR 30 SECONDS AND

MULTIPLY THE NUMBER TIMES 2 TO GET THE PULSE

RATE FOR 1 MINUTE

WE NOTE THE RHYTHM (PATTERN)

OF THE HEART BEAT – IF THE HEART

BEAT IS IRREGULAR WE COUNT THE

PULSE FOR A FULL MINUTE

WE ALSO OBSERVE THE FORCE

(STRENGTH) OF THE HEARTBEAT.

DOES THE PULSE FEEL :

STRONG FULL BOUNDING

WEAK THREADY FEEBLE

o MOST COMMON SITE USED FOR

TAKING A PULSE

o CAN BE TAKEN WITHOUT

DISTURBING OR EXPOSING THE

PERSON

o PLACE THE FIRST TWO OR THREE

FINGERS OF ONE HAND AGAINST THE

RADIAL ARTERY

o THE RADIAL ARTERY IS ON THE

THUMB SIDE OF THE WRIST

o DO NOT USE YOUR THUMB TO TAKE

A PERSON’S PULSE

o USE GENTLE PRESSURE

o COUNT THE PULSE FOR 30 SECONDS

AND MULTIPLY BY TWO

.

5

ALWAYS CLEAN THE

EARPIECES OF THE

STETHOSCOPE WITH

ALCOHOL BEFORE AND AFTER

USE

WARM THE DIAPHRAGM IN

YOUR HAND BEFORE PLACING

IT ON THE PERSON

HOLD THE DIAPHRAGM IN

PLACE OVER THE ARTERY

DO NOT LET THE TUBING

STRIKE AGAINST ANYTHING

WHILE THE STETHOSCOPE IS

BEING USED

o TAKEN WITH A STETHOSCOPE

o COUNTED BY PLACING THE STETHOSCOPE

OVER THE HEART

o COUNTED FOR ONE FULL MINUTE

o THE HEART BEAT NORMALLY SOUNDS LIKE A

LUB-DUB. EACH LUB-DUB IS COUNTED AS ONE

HEARTBEAT.

o DO NOT COUNT THE LUB AS ONE HEARTBEAT

AND THE DUB AS ANOTHER.

o THE APICAL PULSE IS TAKEN ON PATIENTS WHO

HAVE HEART DISEASE , AN IRREGULAR PULSE

RATE, OR TAKE MEDICATIONS THAT CAN AFFECT

THE HEART.

THE APICAL AND RADIAL PULSE RATES SHOULD BE EQUAL

SOMETIMES THE HEART BEAT IS NOT STRONG ENOUGH TO CREATE A PULSE IN

THE RADIAL ARTERY

THIS WOULD CAUSE THE RADIAL PULSE TO BE LESS THAN THE APICAL PULSE

ONE PERSON COUNTS THE APICAL WHILE THE OTHER PERSON COUNTS THE

RADIAL

THE DIFFERENCE IN PULSES IS CALLED THE PULSE DEFICIT

NORMAL ADULT PULSE RATE IS – 60 TO 100 BEATS PER MIN.

TACHYCARDIA – HEART RATE OVER 100

BRADYCARDIA – HEART RATE BELOW 60

REPORT ABNORMAL HEART RATES TO THE NURSE

IMMEDIATELY

ONE RESPIRATION CONSISTS OF ONE INSPIRATION AND

ONE EXPIRATION

o THE CHEST RISES DURING INSPIRATION (BREATHING IN)

AND FALLS DURING EXPIRATION (BREATHING OUT)

o COUNT EACH TIME THE CHEST RISES

o COUNT FOR 30 SECONDS AND MULTIPLY X 2

o DO NOT LET THE PERSON KNOW YOU ARE COUNTING

THEIR RESPIRATIONS

o COUNT AFTER TAKING THE PULSE – KEEP YOUR FINGERS

ON THE PULSE SITE

o NORMAL RESPIRATORY RATE FOR ADULT IS 12 – 20

BREATHS PER MIN.

TACHYPNEA – RESPIRATORY RATE OVER 20

BRADYPNEA – RESPIRATORY RATE BELOW 12

DYSPNEA – SHORTNESS OF BREATH – DIFFICULTY IN

BREATHING

APNEA – NO BREATHING

HYPERVENTILATION – FAST AND DEEP RESPIRATIONS

HYPOVENTILATION – SLOW AND SHALLOW RESPIRATIONS

.

6

THE MEASUREMENT OF THE AMOUNT OF FORCE THE BLOOD

EXERTS AGAINST THE ARTERY WALLS

o SYSTOLIC PRESSURE – PRESSURE EXERTED WHEN THE

HEART MUSCLE IS CONTRACTING

o DIASTOLIC PRESSURE – PRESSURE EXERTED WHEN THE

HEART MUSCLE IS RELAXING BETWEEN BEATS

BLOOD PRESSURE IS RECORDED AS A FRACTION WITH THE

SYSTOLIC PRESSURE ON TOP AND THE DIASTOLIC PRESSURE

ON THE BOTTOM

SYSTOLIC SYSTOLIC /DIASTOLIC

DIASTOLIC 120/80

BP IS MEASURED IN MM (MILLIMETERS) OF HG (MERCURY)

AVERAGE ADULT SYSTOLIC RANGE – 100 TO 140

AVERAGE ADULT DIASTOLIC RANGE – 60 TO 90

HYPERTENSION – MEASUREMENTS ABOVE THE NORMAL

SYSTOLIC OR DIASTOLIC PRESSURES

HYPOTENSION – MEASUREMENTS BELOW THE NORMAL

SYSTOLIC OR DIASTOLIC PRESSURES

o AGE – BLOOD PRESSURE INCREASES AS A PERSON GROWS OLDER.

o GENDER – WOMEN USUALLY HAVE LOWER BLOOD PRESSURE THAN MEN

o BLOOD VOLUME – SEVERE BLEEDING LOWERS THE BLOOD PRESSURE

o STRESS – HEART RATE AND BLOOD PRESSURE INCREASE AS PART OF THE

BODY’S RESPONSE TO STRESS

o PAIN – INCREASES BLOOD PRESSURE

o EXERCISE – INCREASES HEART RATE AND BLOOD PRESSURE

o WEIGHT – BLOOD PRESSURE IS HIGHER IN OVERWEIGHT PERSONS

o RACE – BLACK PERSONS GENERALLY HAVE HIGHER BLOOD PRESSURE

THAN WHITE PERSONS DO

o DIET – A HIGH-SODIUM DIET INCREASES THE FLUID VOLUME IN THE BODY

WHICH INCREASES BLOOD PRESSURE

o MEDICATIONS – CAN BE TAKEN TO RAISE OR LOWER BLOOD PRESSURE

o POSITION – BLOOD PRESSURE IS LOWER WHEN LYING DOWN

THE PROPER NAME FOR A BLOOD PRESSURE CUFF IS

SPHYGMOMANOMETER

MERCURY ANEROID

o DO NOT TAKE A BLOOD PRESSURE ON AN ARM WITH AN IV, A CAST, OR A

DIALYSIS SHUNT.

o DO NOT TAKE A BLOOD PRESSURE ON THE SIDE THAT A PERSON HAS HAD

BREAST SURGERY ON.

o MEASURE BLOOD PRESSURE WITH THE PERSON SITTING OR LYING.

o APPLY THE CUFF TO THE BARE UPPER ARM. DO NOT APPLY THE CUFF

OVER CLOTHING.

o MAKE SURE THE CUFF IS SNUG.

o USE A LARGE CUFF IF NECESSARY.

o MAKE SURE THE ROOM IS QUIET.

o IF YOU DO NOT HEAR THE BLOOD PRESSURE, WAIT 30 TO 60 SECONDS

AND TRY AGAIN. IF YOU STILL CAN NOT HEAR IT OR ARE UNSURE OF

YOUR READINGS, HAVE THE NURSE CHECK YOUR MEASUREMENTS.

.

7

1. CLEAN THE STETHOSCOPE EARPIECES AND DIAPHRAGM WITH ALCOHOL.

2. LOCATE THE BRACHIAL PULSE. THIS IS WHERE THE STETOSCOPE WILL BE PLACED.

3. WRAP THE CUFF ABOVE THE ELBOW WITH THE ARROW POINTING TO THE BRACHIAL

ARTERY. FASTEN THE CUFF SO IT FITS SNUGLY.

4. PLACE THE DIAPHRAGM OF THE STETHOSCOPE FLAT ON THE PULSE SITE, HOLDING IT

IN PLACE WITH THE INDEX AND MIDDLE FINGERS OF ONE HAND.

5. LOCATE THE RADIAL PULSE.

6. CLOSE THE VALVE ON THE BP CUFF BY TURNING IT TO THE RIGHT (CLOCKWISE).

7. INFLATE THE CUFF UNTIL YOU CAN NO LONGER FEEL THE RADIAL PULSE. ,THEN

INFLATE THE CUFF 30 MM HG BEYOND THIS POINT.

8. DEFLATE THE CUFF SLOWLY BY OPENING THE VALVE SLIGHTLY AND TURNING IT

COUNTERCLOCKWISE (TO THE LEFT) WITH YOUR THUMB AND INDEX FINGER. ALLOW

THE AIR TO ESCAPE SLOWLY WHILE LISTENING FOR A PULSE SOUND.

9. NOTE THE READING AT WHICH YOU HEAR THE FIRST CLEAR, REGULAR PULSE SOUND.

THIS NUMBER IS THE SYSTOLIC PRESSURE.

10. CONTINUE LISTENING UNTIL THE SOUND DISAPPEARS. THIS IS THE DIASTOLIC

PRESSURE. NOTE THIS READING.

11. OPEN THE VALVE COMPLETELY TO DEFLATE THE CUFF. REMOVE THE CUFF FROM THE

PATIENT.

MEASURING WEIGHT AND HEIGHT

• Standing, chair, and lift scales are used.

• Measuring weight and height

– The person only wears a gown or pajamas.

– The person voids before being weighed.

– Weigh the person at the same time of day.

– Use the same scale.

– Balance the scale at zero before weighing the

person.

PAIN • Pain means to ache, hurt, or be sore.

• Pain is a warning from the body.

• Pain is personal.

• Types of pain

– Acute pain – felt suddenly from an injury,

disease, trauma, or surgery

– Chronic pain – lasts longer than 6 months. Pain

can be constant or occur on and off.

– Radiating pain – felt at the site of tissue damage

and in nearby areas.

– Phantom pain – felt in a body part that is no

longer there.

.

8

• Signs and symptoms

– Location – Where is the pain?

– Onset and duration – When did the pain start?

– Intensity – Rate the pain on a scale of 1 to 10, with 10 as

the most severe

– Description – Can you use words to describe the pain?

– Factors causing pain – What were you doing when the pain

started?

– Vital signs – Take the person’s vital signs when they

complain of pain.

– Other signs and symptom

• Body responses - ↑ vital signs, nausea, pale skin,

sweating, vomiting

• Behaviors – crying, groaning, holding affected body

part, irritability, restlessness